STATE OF FLORIDA : AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. a Case No. 2009009925 DONEGAN SQUARE HEALTHCARE ASSOCIATES LLC, d/b/a DONEGAN SQUARE VILLAS, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the:undersigned counsel, and files this Administrative Complaint against Donegan Square Healthcare Associates LLC, d/b/a Donegan Square Villas (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2009), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of five hundred dollars ($500.00) based upon one (1) uncorrected cited State Class III deficiency pursuant to §429,19(2)(c), Florida Statutes (2008). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and Chapters 408, Part II, and 429, Part I, Florida Statutes (2009). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable regulations, state statutes and rules governing assisted Filed January 26, 2010 11:58 AM Division of Administrative Hearings. living facilities pursuant to the Chapters 408, Part Il, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 50-bed assisted living facility located at 1090 West Donegan Avenue, Kissimmee, Florida 34741, and is licensed as an assisted living facility with extended congregate care services, license number 5527, 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, residents may keep their medications, both prescription and over-the-counter, in their possession both on or off the facility premises; or in their rooms or apartments, which must be kept locked when residents are absent, unless the medication is ina secure place within the rooms or apartments or in some other secure place which is out of sight of other residents. Rule 58A-5.0185(6)(a), Florida Administrative Code. 8. That on May 12, 2009, the Agency completed a Relicensure Survey of the Respondent facility. 9. That based upon the review of records and observation, Respondent failed to ensure that resident medication, both prescription and over-the-counter, kept in resident rooms or apartments, was maintained in a locked container when the resident was absent from the room or _ apartment or in a secure place within the room or apartment or some secure place out of sight of other residents, the same being contrary to law and noted in a total of six (6) resident rooms or apartments. 10. That Petitioner’s representative toured the Respondent facility on May 12, 2009 commencing at approximately 9:15 AM and noted as follows: 2 a. Resident number one (1) indicated to the Petitioner’s representative as follows: i. ii. iii. iv. vi. vii. The resident self-administered medications; The resident’s pill organizer was kept in a dresser drawer; The drawer was not locked; The medication bottles were kept in a plastic container by the side of the dresser; When the resident left the facility, the resident would place the medication bottles and pill minders in a large purse on the closet’s upper shelf away from others; The resident did not have a key to the room; The resident shared the room with a second resident who was then in a rehabilitation facility and would return. The room of resident number four (4) was closed but unlocked, the resident not in the room and with Liboderm patches and potassium chloride pills by a bedside table; c. The room of resident number eight (8) was open and visible was a bottler of Aspirin 8 mg and underneath a table was a basket with a lid that contained multiple pill bottles; d. Resident number nine (9) indicated to Petitioner’s representative as follows: i. ii, After observing staff assisting with administration of medications, the resident and the resident’s son decided that it would be best if the resident self-administered medications; The resident had a key to the room, but only locked the room when the resident was out of the facility; iii. The resident did not lock the room if the resident was not in the resident’s room but otherwise within the facility. e. Visible within the room of resident number nine (9) during the conversation was a pill organizer on the top of the dresser; f. Medication bottles were kept inside a black and white shoe box under a table, 11. That Petitioner’s representative noted the following during medication review on May 12, 2009 at approximately 3:45 PM: a. Respondent’s staff member provided prefilled insulin syringes for resident number four (4); b. There were three (3) cups, one orange, one blue, and one yellow; c. Each cup contained eight (8) syringes; d. The orange cup was labeled “Lantus 55 U,” the blue “Novolog 6 U,” and the yellow “Novolog 40 U “ and “NPH 20 U before breakfast.” e. Staff indicated that the cups were kept in the facility’s kitchenette; f. The kitchenette is located by the dining room; g. Most residents walked by to access common areas and or their rooms; h. The door to the kitchenette and the door to the refrigerator in which the insulin syringes were kept were both open and unlocked; i, The colored cups containing the insulin filled syringes were stored on the right hand shelf inside the refrigerator in plain view; j. The refrigerator was not equipped with a lock; k. Staff indicated that there was a key for the kitchenette but the kitchenette was never locked. 12. That Petitioner’s representatives requested to observe the insulin for resident number three (3) during the survey and noted as follows: 4 a. Respondent’s staff member went to the room of resident number three (3) which was located across from the medication cart; b. Staff produced a plastic cup containing six (6) syringes; c. Each syringe contained 10 U of medication, presumably insulin; d. The resident shared a room with another resident; e. The syringes were stored on the right hand shelve of a refrigerator, f. The refrigerator was not equipped with a lock. 13. That Respondent’s administrator offered no comment upon disclosure of the above facts and the citation issued. 14. That the failure to secure medications in accord with the minimum requirements of law places all residents at risk of intentional or negligent ingestion of medications by the incorrect resident or by the theft or misappropriation of resident medication by staff, other residents, or visitors. 15. 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. 16. That the Agency cited the Respondent for a Class III violation in accordance with Section 429,19(2)(c), Florida Statutes (2009). 17. That the Agency provided a mandated correction date of June 11, 2009. 18. That on June 23, 2009, the Agency completed a re-visit to the Relicensure Survey of the Respondent facility. 19. That based upon the review of records and observation, Respondent failed to ensure that resident medication, both prescription and over-the-counter, kept in resident rooms or apartments, was maintained in a locked container when the resident was absent from the room or apartment or in a secure place within the room or apartment or some secure place out of sight of 5 other residents, the same being contrary to law and noted in a total of six (6) resident rooms or apartments, 20. That Petitioner’s representative made the following observations commencing at approximately 3:00 PM on June 23, 2009: a. Resident number eleven (1): i. The resident’s was resting in bed; ij. The resident explained that the resident had no key to the room and shared the room with a second resident, resident number three (3); iii. There was a small refrigerator in the room which was not equipped with a lock; iv. Inside the reftigerator was an unlocked metal box v. The box contained a bottle of Lantus insulin; vi. A-small key was lying on the top of the television; vii. Respondent’s administrator indicated that the key was the key for the medication box in the refrigerator. b. Resident number three (3): i. The resident sat in the common area of the facility; ii. The resident indicated that the resident’s medications were in the bathroom underneath the sink in a box; iii. The door to the resident’s room was unlocked; iv. The bathroom door was unlocked; y. The medications of the resident were in a box beneath the sink but the box was not locked. c. Resident number four (4): i. The resident was not in the resident’s room; 6 ii. iii. The resident’s room door was unlocked Resident medications were in a box, but the box was not locked. d. Resident number five (5): i, ii. A bottle of antacid was on the table in the resident’s room; The resident shared the room with another resident. e. Resident number nine (9): i. iii. The resident had a medication box containing medications with a lock thereon which was underneath a dresser; ii. The medication box was not locked; The resident indicated that the resident had a key to the room, but only locked the room if the resident left the facility, not if the resident merely left the room to other parts of the facility. f. Resident number nineteen (19); iii. Vv. The resident indicated that the resident was able to self administer insulin and kept the insulin securely in the bathroom; A Lantus insulin pen was in a metal medication box in a drawer in the bathroom vanity; The medication box was unlocked and contained four (4) Lantus insulin pens; An insulin pen was resting atop the vanity counter top; The resident indicated that pen had been utilized that day. 21. That Petitioner’s representative interviewed Respondent’s administrator regarding the above observations who indicated as follows; a. That residents and their families did not understand how to secure medications within locked medication boxes; b. That the residents and their families would be spoken to regarding this issue. 22. That the failure to secure medications in accord with the minimum requirements of law - places all residents at risk of intentional or negligent ingestion of medications by the incorrect resident or by the theft or misappropriation of resident medication by staff, other residents, or visitors. 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 an uncorrected Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). 25. That the Agency provided a mandated correction date of July 22, 2009. 26. That this citation constitutes an uncorrected violation as provided by law. 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 (2009). Respectfully submitted this | 5 day of December, 2009. ie C. Ragano Fla. Bar. No. 45632 Counsel for Petitioner Agency for Health Care Administration 525 Mistor Lake Drive, 330L St. Petersburg, FL 33701 727.552.1526 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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, FL 32308; Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE J HEREBY CERTIFY that a true and correct copy of the foregoing has been se ed by US. Certified Mail, Return Receipt No. 7004 2890 0000 5526 6301 on December /S72009 to Carol Ribas, Administrator, Donegan Square Villas, 1090 West Donegan Avenue, Kissimmee, Florida 34741 and by U.S, Mail, to Corporation Service Company, Registered Agent, 1202 Hays Street, Tallahassee, Florida 32301-2525. Amie C. Ragano Senior Attorney Copies furnished to: Corporation Service Company Registered Agent 1201 Hays Street Tallahassee, FL 32301-2525 (U.S. Mail) Amie C, Ragano, Esq. Asst. General Counsel Agency for Health Care Admin. 525 Mirror Lake Drive, 330L St. Petersburg, Florida 33701 (Interoffice) Carol Ribas, Administrator Donegan Square Villas 1090 West Donegan Avenue Kissimmee, Florida 34741 (US. Certified Mail) Doris Spivey Facility Evaluator Supervisor Agency for Health Care Administration Hurston South Tower 400 West Robinson Street, Suite $309 Orlando, Florida 32801 Unteroffice USPS - Track & Confirm Page 1 of 1 UNITED STATES Bea postal sevice. Home | Sanh Track & Confirm Search Results Label/Receipt Number: 7004 2890 0000 8526 6304 er , Service(s): Certified Mail™ Track & Confinm e Status: Delivered Enter Label/Receip! Number. Your item was delivered at 11:47 AM on December 28, 2009 in SAINT PETERSBURG, FL 33701. Detailed Results: * Delivered, December 28, 2009, 11:47 am, SAINT PETERSBURG, FL 33701 * Undeliverable as Addressed, December 19, 2009, 6:58 am, KISSIMMEE, FL 34744 * Undeliverable as Addressed, December 18, 2009, 10:04 am, KISSIMMEE, FL. 34741 Notification Options Track & Confinn by email Get current event information or updates for your item sent to you or others by email. ( & ct oz SiieMaa = Gustomer Serica = Forms «= Govt Services =» Corogrs §= Privacy Polley Copyright© 2009 USPS. Alt Rights Reserved. NoFEARActGEQ Data FOIA e http://trkenfrm1.smi.usps.com/PTSInternetWeb/InterLabelInquiry.do 01/15/2010

Docket for Case No: 10-000382