STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE . 4% ADMINISTRATION, ) ¥. OS 58 Petitioner, Vv. Case No. 2008003947 ALTERRA HEALTHCARE CORPORATION d/b/a ALTERRA STERLING HOUSE OF FORT MYERS, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration, (hereinafter “the Agency”), by and through the undersigned counsel, and files this administrative complaint against the Respondent, ALTERRA HEALTHCARE CORPORATION d/b/a ALTERRA STERLING HOUSE OF FORT MYERS (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine against an assisted living facility in the amount of ONE THOUSAND DOLLARS ($1,000.00) based upon two (2) uncorrected Class III violations pursuant to Section 429.19(2)(c), Florida Statutes (2007) and to assess a survey fee in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 429.19(7), Florida Statutes (2007). JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part Il, and 429, Part-I, Florida Statutes (2007). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. 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. Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes (2007); Chapter 58A-5, Florida Administrative Code. The Agency may deny, revoke, or suspend any license issued to an assisted living facility, or impose an administrative fine for violations. Sections 408.813, 408.815 and 429.14, Florida Statutes (2007). 5. The Respondent was issued a license by the Agency (License Number 9183) to operate a 60-bed assisted living facility located at 14521 Lakewood Boulevard, Fort Myers, Florida 33919, and was at all times material required to comply with the applicable federal and state regulations, statutes and rules governing assisted living facilities. COUNT I The Respondent Failed To Ensure That A Prescription Drug Was Properly Labeled In Violation Of Rule 58A-5.0185(7)(d), Florida Administrative Code 6: The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, Sections 429.255 and 429.256, Florida Statutes (2007), and Rule 58A-5.0185, Florida Administrative Code, facilities holding a standard, limited mental health, extended congregate care, or limited nursing services license may assist with the self- administration or administration of medications to residents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule. Any change in directions for use of a medication for which the facility is providing assistance with self- administration or administering medication must be accompanied by a written medication order issued and signed by the resident’s health care provider, or a faxed copy of such order. The new directions shall promptly be recorded in the resident’s medication observation record. The facility may then place an “alert” label on the medication container which directs staff to examine the revised directions for use in the medication observation record, or. obtain a revised label from the pharmacist. Rule 58A-5.0185(7)(d), Florida Administrative Code. 8. On or about January 23, 2008 the Agency conducted a Complaint Investigation of the Respondent’s facility (CCR# 2008-000632 and CCR# 2008-000679). 9. Based on medical records reviewed and staff interview, the facility did not provide new directions for two (2) of two (2) resident medications reviewed that medication was appropriately labeled on the medication bottle, Resident number two (2) and Resident number five (5). 10. A review of Resident number two’s (2) medication records revealed the doctor changed the Lasix order from forty (40) milligrams every day to twenty (20) milligrams every day on January 9, 2008. A review of the medication bottle revealed someone wrote with a black magic marker to give Resident number two (2) half of a tablet to equal twenty (20) milligrams. 11. At an interview with the staff nurse on January 23, 2008 at 12:00 p.m. the nurse stated that someone wrote this on the Lasix bottle. 12.. A review of Resident number five’s (5) medications revealed the resident takes Ferrous Sulfate 325 milligrams every day; however, there was a second bottle in the medication cart with a prescription label of 325 milligrams three (3) times a day with meals. 13. Atan interview with the staff nurse on January 23, 2008 at 12:00 p.m., the nurse stated the doctor changed this order to once per day; however, the prescription bottle does not show this change. 14. 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, other than Class I or Class II violations, in violation of Section 429.19(2)(c), Florida Statutes (2007). 15. | The Agency cited the Respondent for a Class IH violation in accordance with Section 429.19(2)(c), Florida Statutes (2007). 16. The Respondent was given a mandatory correction date of February 23, 2008. 17. Onor about March 4, 2008 the Agency conducted a Follow-Up to the Complaint Investigation of Respondent’s facility (CCR# 2008-000632 and CCR# 2008-000679). 18. Based on observation, record review and interview, the facility failed to provide new directions for two (2) of three (3) resident medications reviewed where the direction on the label of the medication container did not match the order from the health care provider, Resident number seven (7) and Resident number eight (8). 19. On March 4, 2008, a review of the Medication Observation Record for Resident number seven (7) revealed an order from the health care provider for Xanax 0.25 mg. take one tablet as needed every six (6) hours for anxiety. A review of the physician's orders revealed this was ordered on February 27, 2008 when Resident number seven (7) returned from the hospital. The previous order dated November 28, 2007 was for Xanax 0.25 mg. take one tablet every eight (8) hours as needed for agitation. 20. A review of the containers,of medication for Resident number seven (7) revealed that there were two (2) containers of Xanax 0.25 mg. One container had directions for one tablet by mouth every eight (8) hours as needed for agitation and the second container had directions for one tablet every six (6) hours as needed for anxiety. There was no direction change label on the container labeled for every eight (8) hours to reflect the new order that the medication could be given every six (6) hours for anxiety. 21. A review of the Medication Observation Record for Resident number eight (8) on March 4, 2008 revealed an order for Miralax 17 gm. in 8 oz. of water or juice by mouth daily. 22. — A review of the bottle of Miralax for Resident number eight (8) revealed the label to read Miralax 17 gm. in 8 oz. of water or juice by mouth as needed daily. 23. There was no label on the medication container indicating the direction change from as needed to a routine daily basis. 24. A further review of the Medication Observation Record for Resident number eight (8) revealed an order for Ditropan ER 10 mg. one tablet by mouth daily. Hand written below this was “(when current supply complete start Smg two tablets daily)”. The physician’s order in the medical record read Ditropan 10 mg. one tablet by mouth daily. The medication bottle container had a label that read Ditropan 5 mg. take two tablets by mouth daily. The label on the medication bottle did not match the physician order of which neither matched the Medication Observation Record. There was no documentation that the health care provider had been contacted for clarification of this order. Further, there was no direction change label on the bottle to reflect that the order from the physician was different from the label. 25. An interview with the administrator on March 4, 2008 revealed that the Xanax order must have been overlooked because Resident number eight (8) received a new container of medication with the correct label. She confirms that a direction change label should have been placed on the incorrect direction label. She stated that she had reviewed the container of Miralax herself and must have overlooked the direction on the label that indicated the medication was as needed. She stated she reviewed the Ditropan last week as well and attempted to coordinate the order and the medication bottle with the Medication Observation Record. 26. This remains an uncorrected deficiency. 27. 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, other than Class I or Class II violations, and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 28. The Respondent’s deficiency constituted an uncorrected Class III violation. 29. The Agency shall impose an administrative fine for a cited Class IIi violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 30. The Respondent was given a mandatory correction date of April 2, 2008. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 429.19(2)(c), Florida Statutes (2007). COUNT II The Respondent Failed To Make Every Reasonable Effort To Ensure That Prescriptions For Residents Who Receive Assistance With Self-Administration Of Medication Or Medication Administration Are Filled Or Refilled In A Timely Manner In Violation Of Rule 58A-5.0185(7)(f), Florida Administrative Code 31. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). | 32. Pursuant to Florida law, Sections 429.255 and 429.256, Florida Statutes (2007), and Rule 58A-5.0185, Florida Administrative Code, facilities holding a standard, limited mental health, extended congregate care, ot limited nursing services license may assist with the self- administration or administration of medications to residents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule. The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self-administration of medication or medication administration are filled or 5.0185(7)(f), Florida Administrative Code. 33. Onor about January 23, 2008 the Agency conducted a Complaint Investigation of the Respondent’s facility (CCR# 2008-000632 and CCR# 2008-000679). 34. Based on medical records reviewed and staff interview, the facility did not ensure one (1) of three (3) resident medications were refilled timely, Resident number five (5). 35. A review of Resident number five’s (5) Medication Observation Record revealed Aricept 10 milligrams twice a day. On January 5, 2008 through January 18, 2008 documentation on the Medication Observation Record revealed the staff signed each entry on the Medication Observation Record for the Aricept with a circle. On the back of the Medication Observation Record the staff documented the medication was not available. 36. An interview with the staff nurse on January 23, 2008 at 11:30 a.m. stated she called Resident number five’s (5) spouse on January 15, 2008, and Resident number five’s (5) spouse did not want Resident number five (5) to have Aricept any more and was withholding the medication. The staff nurse also stated she talked with the spouse before January 15, 2008, but could not remember when, concerning the withholding of the Aricept. 37. An interview with the Advanced Registered Nurse Practitioner on January 23, 2008 at 11:30 a.m. stated she does not know why Resident number five (5) was not receiving the Aricept but discontinued the use of the Aricept on January 18, 2008. The facility did not provide Resident number five 5) with the Aricept prior to the discontinuation of the medication by the physician and there was no documentation as to why the medication was withheld other than the medication was not available. 38. 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, other than Class I or refilled in a timely manner. Rule 58A-5.0185(7)(f), Florida Administrative Code. 33. Onor about January 23, 2008 the Agency conducted a Complaint Investigation of the Respondent’s facility (CCR# 2008-000632 and CCR# 2008-000679). 34. Based on medical records reviewed and staff interview, the facility did not ensure one (1) of three (3) resident medications were refilled timely, Resident number five (5). 35. A review of Resident number five’s (5) Medication Observation Record revealed Aricept 10 milligrams twice a day. On January 5, 2008 through January 18, 2008 documentation on the Medication Observation Record revealed the staff signed each entry on the Medication Observation Record for the Aricept with a circle. On the back of the Medication Observation Record the staff documented the medication was not available. 36. An interview with the staff nurse on January 23, 2008 at 11:30 a.m. stated she called Resident number five’s (5) spouse on January 15, 2008, and Resident number five’s (5) spouse did not want Resident number five (5) to have Aricept any more and was withholding the medication. The staff nurse also stated she talked with the spouse before January 15, 2008, but could not remember when, concerning the withholding of the Aricept. 37. An interview with the Advanced Registered Nurse Practitioner on January 23, 2008 at 11:30 a.m. stated she does not know why Resident number five (5) was not receiving the Aricept but discontinued the use of the Aricept on January 18, 2008. The facility did not provide Resident number five (5) with the Aricept prior to the discontinuation of the medication by the physician and there was no documentation as to why the medication was withheld other than the medication was not available. 38. . 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, other than Class I or Class II violations, in violation of Section 429.19(2)(c), Florida Statutes (2007). 39. | The Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2007). 40. The Respondent was given a mandatory correction date of February 23, 2008. 41. On or about March 4, 2008 the Agency conducted a Follow-Up to the Complaint Investigation of Respondent’s facility (CCR# 2008-000632 and CCR# 2008-000679). 42. Based on record review and interview, the facility failed to ensure that medications were refilled in a timely manner for one (1) of three (3) medication records reviewed, Resident number eight (8). 43. A review of the Medication Observation Record for Resident number eight (8) on March 4, 2008 revealed an order for Prilosec 20 mg. take one tablet by mouth daily and Tylenol 325 mg. take two (2) tablets by mouth every six (6) hours as needed for pain. Tylenol was last documented as received by Resident number eight (8) on February 27, 2008. 44. A review of the medication drawer where the medications for Resident number eight (8) are kept revealed there was no container of Prilosec or Tylenol. 45. An interview with the staff Licensed Practical Nurse on March 4, 2008 confirmed there was no Prilosec or Tylenol for Resident number eight (8). She stated that the family for Resident number eight (8) provides his/her medication. She stated that when she arrived at work on March 3, 2008 in the moming, there was an empty container for the Prilosec. She reported that she had reordered the medication and contacted the family to bring the medication to the facility, but they had not done so at this time. It is unknown when the Tylenol became unavailable. 46. An interview with the administrator on March 4, 2008 revealed that she had instructed staff last week to reorder the Tylenol when she realized the amount was low, but as of the time of the survey there is no Tylenol in the cart for Resident number eight (8). 47. This remains an uncorrected deficiency. 48. 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, other than Class I or Class II violations, and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 49. The Respondent’s deficiency constituted an uncorrected Class II violation. 50. | The Agency shall impose an administrative fine for a cited Class III violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 51. The Respondent was given a mandatory correction date of April 2, 2008. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 429.19(2)(c), Florida Statutes (2007). COUNT DI (Assessment of Survey Fee) 52. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) and the allegations in Counts I and II. 53. The Agency conducted a Complaint Investigation (CCR# 2008-000632 and CCR# 2008-000679) of the Respondent’s facility on January 23, 2008. 54. As a result of the Agency’s Complaint Investigation (CCR# 2008-000632 and CCR# 2008-000679), the Respondent was cited for two (2) uncorrected Class III deficiencies. 55. Pursuant to Section 429.19(7), Florida Statutes (2007), the Agency is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee or five hundred dollars ($500.00), to cover the cost of conducting the initial complaint investigation that resulted in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under Section 429.28(3)(c), Florida Statutes (2007), to verify the correction of the violations. 56. In this case, the Agency is authorized to seek a survey fee of five hundred dollars ($500.00). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assess a survey fee against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 429.19(7), Florida Statutes (2007). 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. 2. Impose an administrative fine against the Respondent in the total amount of ONE THOUSAND DOLLARS ($1,000.00). 3. Assess a survey fee in the amount of FIVE HUNDRED DOLLARS ($500.00). 4. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this g@bay of oped , 2008. Ct Daley top fin Senior Attorney Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 NOTICE THE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. IF THE RESPONDENT WANTS TO HIRE AN ATTORNEY, IT/HE/SHE HAS THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS FORM. THE RESPONDENT IS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. THE ELECTION OF RIGHTS FORM SHALL BE MADE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION AND DELIVERED TO: AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BUILDING 3, MAIL STOP 3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form have been served to: Susan Lone, Administrator, Alterra Healthcare Corporation d/b/a Alterra Sterling House of Fort Myers, 14521 Lakewood Boulevard, Fort Myers, Florida 33919, by U.S. Certified Mail, Return Receipt No. 7006 2760 0003 1537 2955, and to CT Corporation System, Registered Agent for Alterra Healthcare Corporation d/b/a Alterra Sterling House of Fort Myers, 1200 South Pine Island Road, Plantation, Florida 33324, by U.S. Certified Mail, Return Receipt No. 7006 2760 0003 1537 2962 on this alll Say of Gxpecl , 2008. hors Bley J x 400 Senior Attorney Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 Copies furnished to: Susan Lone, Administrator Alterra Healthcare Corporation d/b/a Alterra Sterling House of Fort Myers 14521 Lakewood Boulevard Fort Myers, Florida 33919 (U.S. Certified Mail) Mary Daley Jacobs, Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Cnteroffice Mail) CT Corporation System, Registered Agent for Alterra Healthcare Corporation d/b/a Alterra Sterling House of Fort Myers 1200 South Pine Island Road Plantation, Florida 33324 (U. S. Certified Mail) Kriste J. Mennella Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) ; f SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY © aol uP are) Ne D. Is delivery address different from item 12. 1 Yes If YES, enter delivery address below: [1 No | & 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. | lM Attach this card to the back of the mailpiece; : i ___ or on the front if space permits, “3 1. Article Addressed to: 25 Too + | Susan Lone, Administra tor ‘ Al tere Sher lens Hovse of fort thy ers | leg zy Cake wad Povlevard 4 For ¢ myers, Florids 5309 3. Service Type O Certified Mal OO Express Mail 1D Registered C1 Retum Receipt for Merchandise O insured Mail Oc0o.p. 4. Restricted Delivery? (Extra Fee) "2. Article Number ree i — i i ____ (Transfer trom service label) : 7006 2760 0003 1537 2955 1 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 fo, :

Docket for Case No: 08-002588