STATE OF FLORIDA AGENCY FOR HEALTH CARE apmantstRatiohy//Y. 4 9 S by aaa Ay hy Ted AGENCY FOR HEALTH CARE y-S ISS “Aplheg Ie Yn 4h ADMINISTRATION, OS Mo Petitioner, AHCA No.: 2007013801 Vv. Return Receipt Requested: 7004 2890 0000 5525 9440 FLORIDA HOUSING CORP. d/b/a 7004 2890 0000 5525 9457 PALM BEACH ASSISTED LIVING FACILITY, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA’), by and through the undersigned counsel, and files this Administrative Complaint against Florida Housing Corp. d/b/a Palm Beach Assisted Living Facility (hereinafter “Palm Beach Assisted Living Facility”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes, (2007), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $27,500.00 for the protection of the public health, safety and welfare and $500.00 survey fee pursuant to Section 429.19(2) (c), and 429.19(10), Florida Statutes (2007) JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Palm Beach County, pursuant to Section 120.57, Florida Statutes and Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 429, Part I, Florida Statutes (2007), and Chapter 58A-5, Florida Administrative Code. 5. Palm Beach Assisted Living Facility operates a 200- bed assisted living facility located at 534 Datura Street, West Palm Beach, Florida 33401. Palm Beach Assisted Living Facility is licensed as an assisted living facility license number AL7617, with an expiration date of December 30, 2008. Palm Beach Assisted Living Facility was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I PALM BEACH ASSISTED LIVING FACILITY FAILED TO MAINTAIN AN ACCURATE AND UP-TO-DATE MEDICATION OBSERVATION RECORD (MOR) FOR SOME RESIDENTS Rule 58A-5.0185(5) (b), Florida Administrative Code (MEDICATION STANDARDS) UNCORRECTED AND REPEATED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the revisit survey conducted on 8/09/07 and based on record review and interview, the facility failed to maintain an accurate and up-to-date Medication Observation Record (MOR) for 4 out of 13 sampled residents (Resident #'s 3, 7, 8 and 12). 8. During an interview with the Director of Nursing (DON) on 08/09/07 at approximately 12:00 PM, it was reported that Resident #'s 3, 7, 8 and 12 all require and receive assistance with self-administered medications by facility staff. Upon the medication review, during the complaint investigation survey, it was revealed that the facility failed to ensure that Resident #'s 3, 7, 8 and 12, received medications as ordered on a regular basis, as follows: 9. During a review of Resident #3's Medication Observation Record (MOR) dated 07/07, it was revealed that the resident was prescribed the following medication: Fosamax 70 mg, 1 tablet once per week. However, during a further review of the MOR, it was noted that the MOR documented that the ww resident consumed this medication on 07/04/07 and twice during the second week of July 2007, specifically on 07/07/07 and 07/09/07. The MOR lacked documentation (i.e. staff initials) indicating that the resident received assistance with this medication during the remaining portion of July 2007. Further record review and interview with the DON revealed that the facility did not have documentation indicating that the resident's physician was notified of the aforementioned medication discrepancies including the double dosage of the medication that was given during the week of 07/06/07-07/12/07 and the missed dosages during the remaining portion of the month from 07/13/07 to 07/31/07, as previously mentioned. 10. During a review of Resident #7'S Medication Observation Record (MOR) dated 06/2007, 07/2007 and 08/2007, it was revealed that the resident was prescribed the following medication: Albuterol Inhaler Kit 17 GM, Inhale 4 puffs 4 times daily. Upon interview with the DON during the medication review, it was reported that the facility allows the resident to self-administer the medication and keep this medication in his/her possession, at all times. However, during a further review of Resident #7's MOR's, it was noted that the MOR's documented (i.e. staff initials) that the resident received assistance from facility staff with the Albuterol Inhaler 4 times daily from 06/01/07 to 06/30/07, 07/01/07 to 07/31/07 and several. times daily from 08/01/07 to 08/08/07. During a further interview, the DON reported that the facility did not have orders from the resident's physician permitting the resident to self-administer the medication. Further interview and record review revealed that the facility could not assure that the resident appropriately self-administered and consumed the medication, as prescribed by his/her physician. 11. During a review of Resident #8's Medication Observation Record (MOR) dated 07/2007 and 08/2007, it was revealed that the resident was prescribed that following medication: Advair 250/50 #60, Inhale 1 puff twice daily. Upon interview with the DON, during the medication review, it was reported that the facility allows the resident to self- administer the medication and keep this medication in his/her possession, at all times. However, during a further review of Resident #8's MOR's, it was noted that the MOR's documented that the resident received assistance from facility staff with the Advair Inhaler twice daily from 07/01/07.to 07/31/07 and once to twice daily from 08/01/07 to 08/09/07. During a further interview, the DON reported that the facility did not have orders from the resident's physician permitting the resident to self-administer the medication. Further interview and record review revealed that the facility could not assure that the resident appropriately self-administered and consumed the medication, as prescribed by his/her physician. (a) During a further review of Resident #8's MOR's dated 07/2007 and 08/2007, it was revealed that the resident was prescribed the following additional medications: Albuterol Sulfate .83/ML, use 1 vial via nebulizer 3 times daily; and Ipratropium 0.02% Nebulizer Solution, use 1 vial via nebulizer three times daily (b) During a further interview with the DON, it was reported that Resident #8 is currently receiving assistance with the two aforementioned medications through a home health agency. However, during a further interview with the DON and review of Resident #8's MOR's (07/2007 and 08/2007), it was revealed that the facility staff documented (i.e. staff initials), indicating that the resident received assistance from facility staff with the two aforementioned medications from 07/01/07 to 07/31/07 and from 08/01/07 to 08/09/07. (c) During a further review of Resident #8's MOR dated 08/2007, it was revealed that the resident was prescribed the following medications: Zinc Sulfate 200 mg, 1 tablet once daily and Vitamin C 500 mg, 1 tablet once daily. Further review of the MOR revealed that there was no documentation (i.e. staff initials), indicating that the resident received assistance with this medication nor was there documentation explaining the missed doses of the aforementioned medications from 08/01/07 to 08/09/07. 12. During a review of Resident #12's Medication Observation Record (MOR) dated 07/2007 and 08/2007, it was revealed that the resident was prescribed that following medication: Albuterol Inhalation Kit 17 grams, Inhale 1 puff every 6 hours. Upon interview with the DON during the medication review, it was reported that the facility allows _ the resident to self-administer the medication and keep this medication in his/her possession, at all times. However, during a further review of Resident #12's MOR's, it was noted that the MOR's documented that the resident received assistance from facility staff with the Albuterol Inhaler up to four times daily from 07/01/07 to 07/23/07. During a review the resident's MOR dated 08/2007, there was no documentation indicating that the resident received assistance with this medication from 08/01/07 to 08/09/07. During a _ further interview, the DON reported that the facility did not have orders from the resident's physician permitting the resident to self-administer the medication. Further. interview and record review revealed that the facility could not assure that “the resident appropriately self-administered and consumed the medication, as prescribed by his/her physician. 13. During a further interview conducted at approximately 3:00 PM, the DON confirmed the aforementioned discrepancies. This is an uncorrected deficiency from the Operation Spot Check Appraisal Visit conducted on 6/19/07. New mandated date for Correction: 9/08/07. i4. During the second revisit survey conducted on 10/02/07 and Based on record review and interview, the facility failed to maintain an accurate and up-to-date Medication Observation Record (MOR) for 8 out of 13 sampled residents (Resident #'s 1, 2, 3, 4, 6, 8, 11 and 12). 15. During an interview with Medication Technician #1 on 10/02/07 at approximately 1:00 PM, it was reported that Residents #'s 1, 2, 3, 4, 6, 8, 11 and 12 all require and receive assistance with self-administered medications by facility staff. Upon the medication review, accompanied by the Director of Nursing (DON), on 10/02/07 at approximately 1:50 PM, it was revealed that the facility failed to ensure that Resident #'s 1, 2, 3, 4, 6, 8, 11 and 12, received medications as ordered on a regular basis, as follows: 16. During a review of Resident #1's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medications: Hydralazine 50 mg, take 1 tablet three times daily. Carbamazepin 200 mg, take 1 tablet three times daily. (a) During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused these medications on 10/02/07 at 12 PM. (b) During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 12 PM, as ordered by his/her physician. 18. During a review of Resident #2's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medication: Oxycodo-APAP 10-325, take 1 tablet every 6 hours, as needed for pain. (a) During a further review of the MOR, it was revealed that the resident was assisted with this self- administered medication on 10/01/07 at 5:00 PM. Further review of the MOR revealed that the facility staff assisted the resident with a second dose of this medication on 10/01/07. However, there was no documentation by facility staff indicating the exact time that the 2nd dose was given to ensure that sufficient time had lapsed between the time that the 1st dose and 2nd dose was given to the resident, as prescribed by his/her physician. 19. During a review of Resident #3's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medication: Lexapro 20 mg, take one tablet every morning. (a) During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused these medications for two consecutive days including 10/01/07 and 10/02/07 at 8 AM. During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medication on 10/01/07 and 10/02/07 at 8 AM, as ordered by his/her physician. 20. During a review of Resident #4'S Medication Observation Record (MOR) dated 10/2007, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the following medications on 10/02/07 at the designated times, as follows: Omeprazole 20 mg, take 1/2 tablet once daily (8 AM) Thera-M tabs, take one tablet once daily (8 AM) Thiamine HCL 100 mg, take one tablet once daily (8 AM) Folic Acid 1 mg, take 1/2 tablet once daily (8 AM) Calcium Carb, take 1 tablet twice daily (8 AM) Tramadol HCL 50 mg, take 1 tablet three times daily (8 AM and 12 PM) Campral 333 mg, take 1 tablet three times daily (8 AM and 12 PM). (a) During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 8 AM and/or 12 PM, as ordered by his/her physician. (b) During a further review of Resident #4's MOR, the following discrepancies were revealed as follows: The MOR read: Folic Acid 1 mg, take 1/2 tablet once daily. However, the label read: take 1 tablet once daily. b. The MOR read: Tramadol HCL 50 mg, take two tablets three times daily. However, the label read: take two tablets three times daily, as needed for lower back and hip pain. 21. During a review of Resident #6's Medication Observation Record (MOR) dated 10/2007, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the following medications, on 10/02/07 at 8 AM, as ordered by his/her physician, as follows: Fluoxetine 10 mg, take 1 capsule daily. Asprin 325 mg, take 1 tablet daily. Toprol XL 100 mg, take 1 tablet daily. Triamt/HCTZ 37.5 mg, take 1 tablet in the morning. (a) During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 8 AM, as ordered by his/her physician. 22. During a review of Resident #8's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medications: Fluoxetine 20 mg, take 1 capsule daily. Citalopram 20 mg, take 1 capsule daily. (a) During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medications for two consecutive days including 10/01/07 and 10/02/07 at 8 AM. (o) Further review of the MOR revealed that the resident was prescribed the following additional medications: Hydroxyz HCL 25 mg, take 1 capsule daily. Geodon 40 mg, take 1 capsule daily. Amlodipine 10 mg, take 1 tablet daily. (c) During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medications on 10/02/07 at 8 AM. (d) During a further interview with the DON, it was confirmed that the resident did not receive the aforementioned medication on 10/01/07 and 10/02/07 at 8 AM, as ordered by his/her physician. 23. During a review of Resident #11's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medications: Ferrous Sulfate 325 mg, take 1 tablet three times daily. Gabapentin 300 mg, take 2 tablets three times daily. (a) During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medications on 10/02/07 at 12 PM. (b) During a further review of Resident #i1l's MOR, the following discrepancies were revealed as follows: (c) The MOR read: Gabapentin 300 mg, take 2 capsules 3 times daily. However, the label read: take 1 tablet three times daily. 12 24. During a review of Resident #12's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medication: Norvasc 10 mg, take 1 capsule once daily. (a) During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medication on 10/02/07 at 8 AM. (bo) During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 12 PM, as ordered by his/her physician. 25. During an interview with the Administrator at approximately 3:00 PM, the findings were acknowledged. New mandated correction date 11/01/07 26. During a follow-up visit conducted on 11/26/07 and based on record review and interview, the facility failed to Maintain an accurate and up-to-date Medication Observation Record (MOR), for 2 out of 4 sampled residents (Resident #4 & #6). 27. During the Medication Standards portion of the investigation conducted on 11/26/2007 at approximately 12 PM, it was reported that all residents in the facility require and receive assistance with self-administered medications by facility staff. During a further review of the sampled 13 residents' MOR, it was noted that facility did not maintain accurate or up-to-date MORs. The following residents' MORs were noted to be incorrect, specifically: 28. Resident #4 MOR: (a) Staff signed the MOR that all medication were given on 11/9/07-11/11/07 and 11/20/07, when facility records indicated that the resident was not at the facility. (b) MOR missing documentation of missed medications and reason(s) dosages of all prescribed medications not given on 11/9/07-11/11/07 and 11/20/07. (c) Carisoprodol missing documentation of the date of frequency and/or dosage changes as prescribed by the doctor. (d) Cymbalta missing documentation of the date of frequency and/or dosage changes as prescribed by the doctor. (e) Hydrocort missing discontinued date on the MOR. (£) Staff signed the MOR on numerous dates as giving Endocet but frequency (time given) unknown. (g) MOR missing documentation of known allergies. 29. Resident #6: (a) MOR reads Warfarin (5mg). - take two tablets by mouth at bedtime. According to Physician orders date 08/07 resident is take only take 2 tablets on Monday and Friday and all other days to take 1 1/2 tablet (orders taped on wall in medication room, not in resident file). An interview with the 14 DON, revealed that the facility is assisting the resident with this medication according to the new orders not the orders on the MOR. (b) MOR missing documentation of known allergies. (c) MOR missing documentation regarding reason(s) dosage of Codeine was missed on 11/22/07 at 5 PM as ‘prescribed. (d) MOR missing documentation regarding reason(s) dosage of Etodolac was missed on 11/25/07 at 12 PM as prescribed. 30. The Administrator of the facility was interviewed on the day of the survey at approximately 1:45 PM, and after investigation, confirmed the findings. 31. Based on the foregoing, Palm Beach Assisted Living Facility violated Rule 58A-5.0185(5) (b), Florida administrative Code, an uncorrected and repeated Class TIII deficiency, which carries, in this case, an assessed fine of $27,500 ($500 x 55 days from 10/03/07 to 11/26/07). SURVEY FEE Pursuant to Section 429.19(10), Florida statutes, AHCA May assess a survey fee of $500.00 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count T. B. Assess an administrative fine of $27,500.00 against Palm Beach Assisted Living Facility on Count I for the violations cited above. Cc. Assess a survey fee of $500.00 against Palm Beach Assisted Living Facility, pursuant to Sections 429.19(10), and 429.19(2)(c), Florida Statutes (2007). D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. 16 RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THI E FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, Y@U HAV ER. REPRESENTED BY AN ATTORNEY IN THIS THE RIGHT TO BE Tfia Lawton-Russell Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52°¢ Terrace Suite 103 Miami, Florida 33166 (305) 470-6805 Copies furnished to: Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (Inter-office mail) Finance and Accounting Revenue and Management Unit Agency for Health Care Administration 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Roy E. Glucskman, 17 Administrator, Palm Beach Assisted Living Facility, 534 Datura Street, West Palm Beach, Florida 33401, and to Joseph Glucskman, 534 Datyra Street, West Palm Beach, Florida 33401 on We: ' 2008. Tia Lawton-Russell 18 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY © Compiete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. i 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: jf D1 Agent O Addressee EB, 2. Article Number iy tee (Transfer trom. service label) | PS Form 3811, February 200470 SENDER: COMPLETE THIS SECTION COMPLETE TtitS SECTION ON DELIVERY ™ 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. pene Qos fi Agent O Addressee ite of Delivery A Ss D. Is delivery address different from item 1? © Yes If YES, enter delivery address below: ©] No 3. Service Type Mail © Express Mail C Registered Ci-Retafn Receipt for Merchandise Ol insured Mail ~=1C.0.0. 4, Restricted Delivery? (Extra Fee) 2. Article Number (Transfer from service labo) 7004 2890 o000 5525 9457 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 HE 22070/3 £0) Pork

Docket for Case No: 08-005155