STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, . Petitioner, Case No.: 2012005708 vs. ANDRADA SUNSHINE CORPORATION d/b/a GOOP SAMARITAN RETIREMENT HOME, Respondent. / ‘ADMINISTRATIVE COMPLAINT COMES NOW the Agency For Health Care Administration (the “Agency”) and files this administrative complaint against .Andrada Sunshine Corporation d/b/a Good Samaritan Retirement Home, (“Respondent” or “Respondent Facility”), pursuant to §§ 120.569, and 120.57, Fla. Stat., and alleges: NATURE OF THE ACTION This is an action to revoke the license of an assisted living facility, to impose an administrative fine in the amount _ of twenty-seven thousand dollars ($27,000.00) and for such other relief as this tribunal may determine, pursuant to Chapters 408, Part II, and 429, Part I, Fla. Stat. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and 429.07, and Chapters 408, Part II, and 429, Part I, Florida Statutes. Page 1 of 58 Filed June 27, 2012 4:15 PM Division of Administrative Hearings 2. Venue lies pursuant to Fla. Admin. Code R. 28-106. 207. PARTIES 3. The Agency licenses all assisted living facilities and enforces all applicable Florida statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4, -Respondent operates a 65-bed assisted living facility - - located at 507 S.E. lst Avenue, Williston, Florida 32696, and is licensed as an assisted living facility, license number 25. 5. At all times material to this complaint, Respondent was licensed by the Agency and was required to comply with all applicable rules and statutes. 6. Section 408.815, Florida Statutes, provides: (1) In addition to the grounds provided in authorizing statutes, grounds that .may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a- controlling interest: (a) False representation of a material fact in the license application or omission of any material fact from the application. ; . (ob) An intentional or negligent act materially affecting the health or safety of a client of the provider. ‘(c) A violation of this part, authorizing statutes, or applicable rules. : (d) A demonstrated pattern of deficient performance, (e) The applicant, licensee, or controlling interest, has been or is currently excluded, suspended, or _ terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. Page 2 of 58 7. Section 429.14, Florida Statutes, provides: (1) In addition to the requirements of part II of 4 chapter 408, the agency may deny, revoke, and suspend 4 . any license issued under this part and impose an 4 administrative fine in the manner provided in chapter ° 120 against a licensee for a violation of any provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under s. 408.809, or for the actions of any facility employee: 4 (a) An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. (b) . (c) Misappropriation or conversion of the property of i a resident of the facility. i (d).. 4, ‘ (e), A citation of any of the following deficiencies as tts ; specified in s. 429,19: . 1. One or more cited class I deficiencies. j 2. Three or more cited class II deficiencies. a 8. An Immediate Moratorium on Admissions, Agency VERSA ‘number 2012005625, was imposed on Respondent on May 22, 2012. COUNT I AO7 9. The Agency re-alleges and incorporates paragraphs 1 through 8, as if fully set forth in this count. 10. Rule 58A-5.0181, Florida Administrative Code, ' requires: (1) ADMISSION CRITERIA. An individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license: (e) Be capable of taking his/her own medication with assistance from staff if necessary, 1. If the individual needs assistance with self- Page 3 of 58 ~~ aed administration the facility must inform the resident of the professional qualifications of facility staff who will be providing this assistance, and if unlicensed staff will be providing such assistance, obtain the resident’s or the resident's surrogate, guardian, or attorney-in-fact’s written informed consent to. provide such assistance as required under Section 429.256, F.S. 2. The facility may accept a resident who requires the administration of medication, if the facility has a nurse to provide this service, or the resident or the resident's legal representative, designee, surrogate, guardian, or attorney in fact contracts with a licensed third party to provide this service to the resident. ; (£) Any special dietary needs can be met by the facility. . (n) Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator shall base the decision on: 1. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429,26, F.S., and subsection (2) of this rule; — 2. The facility’s admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs; and (2) HEALTH ASSESSMENT. As part of the admission criteria, an individual must undergo a face-to-face medical examination completed by a licensed health care provider, as specified in either paragraph (a) or (b) of this subsection, (a) A medical examination completed within 60 calendar days prior to the individual’s admission to a facility pursuant to Section 429.26(4), F.S. The examination must address the following: 1. The physical and mental status of the resident, including the identification of any health-related problems and functional limitations; 2. An evaluation of whether the individual will require supervision or assistance with the activities of daily living; 3. Any nursing or therapy services required by the individual; 4. Any special diet required by the individual; Page 4 of 58 5. A list of current medications prescribed, and whether the individual will require any assistance with the administration of medication; 6. Whether the individual has signs or symptoms of a communicable disease which is likely to be transmitted to other residents or staff; 7. A statement on the day of the examination that, in the opinion of the examining licensed health care provider, the individual’s needs can be met in an assisted living facility; and 8. The date of the examination, and the name, signature, address, phone’ number, and license number of the examining licensed health care provider. The medical examination may be conducted by a currently licensed health care provider from another state. (b) A medical examination completed after the resident’s admission to the facility within 30 calendar days of the admission date. The examination must be recorded on AHCA Form 1823, Resident Health Assessment for Assisted Living Facilities, October 2010. The form is hereby incorporated by reference. A faxed copy of the completed form is acceptable. A copy of AHCA Form 1823 may be obtained from the Agency Central Office or its website at www. fdhc.state. £1.us/MCHQ/Long_Term_Care/ Assisted_living/pdf/AHCA_Form_1823%.pdf. The form must be completed as follows: 1. The resident’s licensed health care provider must complete all of the required information in Sections 1, Health Assessment, and 2, Self-Care and General Oversight Assessment, a. Items on the form that may have been omitted by the licensed health care provider during the examination do not necessarily require an additional face-to-face examination for completion. b. The facility may obtain the omitted information either verbally or in writing from the licensed health care provider. c, Omitted information received verbally must be documented in the resident’s record, including the name of the licensed health care provider, the name of the facility staff recording the information and the date the information was provided. 2. The facility administrator, or designee, must complete Section 3 of the form, Services Offered or Arranged by the Facility, or may use electronic documentation, which at a minimum includes the Page 5 of 58 elements in Section 3. This requirement does not apply for. residents receiving: a. Extended congregate care (ECC) services in facilities holding an ECC license; b. Services under community living support plans in facilities holding limited mental health licenses; c. Medicaid assistive care services; and d. Medicaid waiver services. (c) Any information required by paragraph (a) that is not contained in the medical examination report conducted prior to the individual's admission to the: facility must be obtained by the administrator within 30 days after admission using AHCA Form 1823. (£) Any orders for medications, nursing, therapeutic diets, or other services to be provided or supervised by the facility issued by the licensed health care provider conducting the medical examination may be attached to the health assessment. A licensed health care provider may attach a do-not-resuscitate order for residents who do not wish cardiopulmonary resuscitation to be administered in the case of cardiac or respiratory arrest. (4) CONTINUED RESIDENCY. Except as follows in paragraphs (a) through (e) of this subsection, criteria for continued residency in any licensed facility shall be the same as the criteria for admission. As part of the continued residency _ criteria, a resident must have a face-to-face medical examination by a licensed health care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant change is defined in Rule 58A-5.0131, F.A.C. The results of the examination must be recorded on AHCA Form 1823, which is incorporated by reference in paragraph (2) (b) of this rule. The form must be completed in accordance with that paragraph. After the effective date of this rule, providers shall have up to 12 months to comply with this requirement, (ad) The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. (Sy DISCHARGE. If the resident no longer meets the criteria for continued residency, or the facility is Page 6 of 58 unable to meet the resident’s needs, as determined by the facility administrator or licensed health care provider, the resident shall be discharged in accordance with Section 429.28(1), F.S. 11. The Agency conducted an unannounced monitoring survey of the Respondent’s assisted living facility on May 17 through 20, 2012. 12. Based on the Agency’s surveyor'’s review of Respondent’s records and on interviews, the Agency concluded that the Respondent's Administrator failed to become fully aware of, and adequately assess for residency, the needs of one (1) resident, Resident #23, as ‘listed on the resident’s health assessment form, prior to admission into the Respondent! s assisted living facility, of the forty-two (42) residents whose care was reviewed by the Agency. — . 13. The Agency’s surveyor’s review of Resident #23's record revealed an admitting health assessment dated 08/15/2011. 13.a. Resident #23’s.health assessment stated that the resident was to be on a 2,000 calorie, diabetic diet. 13.b. According to the health assessment, Resident #23 requires medication administration, 13.c. Further review of Resident #23's record revealed a Physician's Order-Discharge Medications sheet from a named hospital, dated 08/13/11. According to this document, Resident #23 was to continue his Lantus Insulin, Page 7 of 58 subcutaneous. A hand-written notation indicates that this was a home medication. Review of a named home health agency's Interdisciplinary Communication Record revealed the home health agency has documented Resident #23's vital ‘signs on 3/21, 3/27, 3/30, 4/3, and 5/2. Further review of the home health document revealed that on 5/2 the resident's blood sugar was 119, There was no other ‘notation that the home health agency was checking Resident #23's blood sugar or that-anyone from the home: health agency was administering insulin or any of other . medications to Resident #23. 13.d. The Agency's surveyor’s review of the Respondent’s Resident Observation Log found an entry dated 5/10/2012 stating, "Resident sent to the hospital due to body weakness and episodes of low blood sugar.” The entry was signed by Respondent’s medication technician (“med tech”). 13.e. Resident #23's diagnoses are diabetes, obstructive uropathy, renal insufficiency and hypertension. 14, The Agency’s surveyor interviewed Respondent's Administrator on 05/19/2012 at 12:30 PM. The Agency's surveyor _was told that Resident #23 is not on insulin, and that he has never seen him on insulin. The discharge record was shown to the Administrator, but the Administrator stated that he was not Page 8 of 58 aware of the information on the discharge record. The Administrator indicated that Resident #23 checks his own blood sugar, but he has not been taking insulin since he was admitted to the Respondent's facility. 15. The Agency determined that the Respondent’ s Administrator’s above-described failure to review Resident #23's health assessment, failure to become aware of Resident #23's needs, and failure to assess whether or not the Respondent’ s assisted living facility could or would provide care and services appropriate to the needs of Resident #23 is a violation of law and describes conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be a class IT violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes, WHEREFORE, the Agency intends to impose an administrative fine in the amount of $3,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described Class II violations, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT ITI Al0 Page 9 of 58 16. The Agency re-alleges and incorporates paragraphs 1 through 8 and paragraph 10, as if fully set forth in this count. 17. Rule 58A-5.0131 (33), Florida Administrative Code, defines: (33) “Significant change” means a sudden or major shift in behavior or mood, or a deterioration in health status such as unplanned weight change, stroke, heart condition, or stage 2, 3, or 4 pressure sore. Ordinary day-to-day fluctuations in functioning and behavior, a short-term illness such as a cold, or the gradual deterioration in the ability to carry out the activities of daily living that accompanies the aging process are not considered significant changes. 18. The Agency conducted an unannounced monitoring survey . of the Respondent’s assisted living facility on May 17 through 20, 2012. 19. Based on the Agency’s surveyors’ review of Respondent’s records, observations and interviews, the Agency “concluded that the Respondent facility failed to obtain a new health assessment .after the resident suffered a significant change in condition for two (2) residents, Resident #2 and Resident #15, of the forty-two residents whose care was reviewed by the Agency. 20. Specifically, Respondent’s failure to have a revised health assessment completed following significant changes in condition of Residents #2 and #15 resulted’ in the facility not being aware that Resident #2's diet changed to mechanical soft, and that Resident #15’s diet needed to be changed to pureed or Page 10 of 58 ad Ne, , mechanical soft. 21. The Agency’s surveyors’ review of Resident #2's record revealed that Resident #2's most recent health assessment was dated 9/26/2011. The resident has listed medical diagnosis of diabetes, hypertension, GERD, Vitamin B12 deficient, Urinary incontinence and corp. Further review of the-health assessment revealed that the resident was to be on a Diabetic Diet. 22. A Diabetic Diet is generally characterized by a diet which is high in fiber, with a variety of fruit and vegetables, and low in both sugar and fat, especially saturated fat. 23. The Agency’s surveyors’ further review of Respondent’s records for Resident #2 found a record of Resident #2’s hospitalization, Resident #2’s hospital discharge instructions dated 01/02/2012 stated that the resident was discharged with orders requiring: "Custom diet at discharge. Mechanical soft." Further review of the hospital record revealed the section entitled "Hospital Course. Raview of this section revealed,-"A [computed tomography] CT of the chest was done and appeared to show chronic aspiration pneumonia." The end of this section stated, "She will remain on the mechanical soft diet as recommended by the speech therapist who performed the swallow evaluation." Further review of the resident's record failed to reveal an up-dated health assessment completed after Resident #2's significant change in condition which required Resident #2 Page 11 of 58 i to now have a mechanical soft diet. on 24. A mechanical soft diet may be prescribed for patients 4 who have difficulty chewing or swallowing. The foods 4 recommended are chopped, ground, or blenderized and prepared with added liquids to make them easier for the patient to eat, 25. The Agency’s surveyor observed Resident #2 on 05/18/2012 at 5:15 PM, during the evening meal. Rather than the required mechanical soft diet, Resident #2 was eating a salad that consisted of lettuce, cucumber cut in quarters, tomatoes, 1/4 slice of egg, 3 long strips of chicken, and 4 Saltine erackers. The Agency’s surveyor observed members of Respondent’s staff place the salad in front of the resident, and then walk away. No one cut the chicken strips or the egg for : the resident. After everyone was served the salad, a member of Respondent’s staff put a cup of watermelon cut in large chunks next to Resident #2. ; 26. The Agency's surveyor again observed Resident #2 on 05/20/2012 at‘11:52 aM, Quring Respondent’s lunch ‘time meal. again, members of Respondent's staff served Resident #2 a regular meal. The lunch consisted of a thick piece of meatloaf, half a baked potato, and mixed vegetables. A member of Respondent’s staff was observed putting butter on Resident #2's baked potato and then walking away. At 12:01 PM, Resident. #2 was observed to have eaten only the middle of the baked potato - Page 12 of 58 2 the area without .butter was not touched - and about 1/4 of her meatloaf. Once again, all residents,. including Resident #2, were served large chunks of watermelon with her meal. Resident #2 left the remainder of her lunch on the plate, putting her napkin over it. No member of Respondent's staff talked to Resident #2 about the meal. 27. The Agency’s surveyor also observed that Resident #2 did not eat her dinner on 05/20/2012. No member of Respondent's staff appeared to notice that Residerit #2 had not eaten. 28. The Agency’s surveyors interviewed the Respondent’ s Administrator on 05/18/2012 at 4:45 PM. The Administrator told the Agency’s surveyors that he was not sure why no one caught the change in diet order for Resident #2. 29. On 05/18/2012 at 5:01 PM, the Agency’s surveyor interviewed Respondent’s Mediation Technician (“Med Tech”) B. Med Tech B stated that Resident #15 receives her medication crushed and in apple sauce because she has difficulty swallowing. 29.a. The Agency’s surveyor’s review of Resident #15's record revealed a physician's telephone order for the resident's medication to be crushed and placed in apple sauce. 29.6. Review of Resident #15's 04/25/2012 health assessment revealed she is to have a regular diet. Page 13 of 58 29.c. On 05/18/2012 at 5:01 PM, the Agency's surveyor observed Resident #15, Respondent’s staff cut up her small salad into small pieces, Resident #15 was observed picking up tiny bits of cheese at a time to eat. 30. The Agency determined that the Respondent’ s Administrator's above-described failure to obtain a new health assessment for Resident #2 following Resident #2's hospitalization and for Resident #15 following Resident #15’ 5s physician's recognition of Resident #15's difficulty in swallowing are each a violation of law and describe conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes, WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violations, pursuant to Chapters 408, Part II, and 429, ’ Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT IIT A025 31. The Agency re-alleges and incorporates Paragraphs 1 Page 14 of 58 through 8 and paragraphs 21 through 28, as if fully set forth in this count. 32. Rule 58A-5.0182, Florida Administrative Code, requires: 58A-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident's whereabouts. The resident may travel independently in the community. (d) Contacting the resident's health care provider and other appropriate party such as the resident's family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident's family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A- 5.0131(33), P.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services, (3) ARRANGEMENT FOR HEALTH CARE. In order to facilitate resident access to needed health care, the facility shall, as needed by each resident: (a) Assist residents in making appointments and remind residents about scheduled appointments for medical, dental, nursing, or mental health services. (b) Provide transportation to needed medical, dental, nursing or mental health services, or arrange for transportation through family and friends, volunteers, taxi cabs, public buses, and agencies providing Page 15 of 58 ~e Se transportation for persons with disabilities. | (c) The facility may not require residents to see a 4 particular health care provider. y 33. ‘Rule 58A-5.020, Florida Administrative Code, requires: — (1) . GENERAL RESPONSIBILITIES. When food service is { provided by the facility, the administrator or a person designated in writing by the administrator shall: (a) Be responsible for total food services and the day to day supervision of food services staff. j (b). Perform his/her duties in a safe and sanitary “4 manner. ; , (c}) Provide regular meals which meet the nutritional needs of residents, and therapeutic diets as ordered by the resident's health care provider for resident's who require special diets. - (2) DIETARY STANDARDS. yo (6) Therapeutic diets shall be prepared and served as \ "ordered by the health care provider. ; 1. Facilities that offer residents a variety of food | choices through a select menu, buffet style dining or 4 ; family style dining are not required to document what is eaten unless a health: care provider’s order indicates that such monitoring is necessary, However, the food items which enable residents to comply with the therapeutic diet shall be identified on the menus developed for use in the facility. 2. The facility shall document a resident's refusal to comply with a therapeutic diet and notification to the resident’s health care provider of such refusal. If a i - resident refuses to follow a therapeutic diet after : the benefits are explained, a signed statement from the resident or the resident's responsible party vefusing the diet is acceptable Qaocumentation of a resident’s preferences. In such instances daily documentation is not necessary, 34. On November 30 and December 1, 2011, the Agency i conducted a complaint investigation survey of the Respondent, 35. Based on the Agency’s surveyor’s interviews, review of ! , Page 16 of 58 Fo ee I av Respondent’s records and observations, the Agency concluded that the Respondent failed to meet the medical needs of one resident, Resident #1, of the two residents whose care was reviewed by the Agency's surveyor, . 36. On November 30, 2011, at 1:00 p.m., the Agency’s surveyor conducted an interview with Respondent’ s administrator. Respondent's administrator stated that no podiatrist is scheduled to come to the facility. ‘Residents have not been seen by a podiatrist in an unknown amount of time, 37, The Agency’s surveyor’s review of Respondent’s records for Resident #1 revealed that Resident #1 was seen by her physician on 7-18-2011 and again on 11-14-2011, and an order was given each time for Resident #1 to be seen by a podiatrist ‘ within a week and for blood pressure monitoring. 38. However, Respondent did not assist Resident #1 in making an appointment until a third order was received. A referral on 12-6-2011 to a podiatrist was made by a member of Respondent's staff for Resident #1 after Resident #1’s physician gave a third order on 11-21-2011. 39, Respondent had no documentation for blood pressure monitoring for Resident #1’s blood pressure for the last six months prior to the Agency’s survey of November 30 and December 1, 2011. 40. The Agency’s surveyor, who is a Registered Nurse, Page 17 of 58 observed Resident #1 on 11-30-2011.at 1:30 PM. Resident's right great toe was red and swollen; the toenail appeared to be lifting away from the nail bed, 41. On 11-30-2011 at 1:30 PM, the Agency’s surveyor interviewed Resident #1. Resident #1 stated that she had not been seen by a podiatrist, and that she has been having pain in her toe for several months. 42, The Agency determined that the Respondent's above- described failure to provide care and services appropriate to the needs of Resident #1 is a violation of law and describes conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. 43. The Agency conducted an unannounced monitoring survey of the Respondent's assisted living facility on May 17 through 20, 2012, . . 44. Based on the Agency’s surveyors’ review of Respondent’s records, observations and interviews, the Agency concluded that the Respondent facility failed to monitor the quantity and quality of resident’s diets and failed to provide therapeutic diets in accord with health care provider's orders Page 18 of 58 w ~~ for eight (8) - Residents #1, #2, #11, #12, #23, #25, #26, and #29 - of the forty-two (42) residents whose care was reviewed by the Agency’s surveyors. 45. The Agency’s surveyors’ review of Respondent’s records for Resident #1 found that Resident #1 was admitted to the Respondent’s facility on 8/23/2011. Resident #1 was re-admitted to the facility from the hospital on 12/19/2011. Diagnoses included hypertension, diabetes, bi-polar disorder, coronary artery disease, and stroke with left side weakness. 45.a. Resident #1 was ordered to be on a No Concentrated Sweets, No Added Salt diet with Pureed consistency per physician order dated 10/14/2011 as noted on Resident Health Assessment (AHCA form 1823). . 45.b, The Agency’s surveyor’s review of Respondent’ s records for Resident #1 found a Resident Observation Log entry dated 1/29/2012 stating that Resident #1 was observed “to be choking in the dining room during lunch time. Heimlich maneuver was performed on. Resident #1 and pieces of meat came out. Further record review revealed another ‘Resident Observation Log entry dated 1/30/2012 which stated that the Respondent received a call from the hospital advising that Resident #1 has passed away. The Agency's surveyors’ review of Resident #1's Florida Certificate of Death revealed that the resident's cause of death was Page 19 of 58 ad Ww aspiration, 45.c. “Aspiration” refers to the accidental sucking in of food particles or fluids into the lungs. 45.d. On 5/17/2012 at 1:20 PM, the Agency’s surveyor conducted an interview with Respondent’s Med Tech. The Med Tech stated to the Agency’s surveyor that she was present in the dining room on 1/29/2012. She heard Resident #1 cry out and noticed his hand was holding his throat, and he was spitting out meat. Respondent’ s Certified Nursing Assistant (“CNA”) checked resident #1's mouth and saw more meat. . She called out for 911 to be called and did the Heimlich maneuver 3 times. Resident #1 lost consciousness. “An ambulance arrived, and the paramedics opened Resident #1" 8 airway, but the resident did not regain consciousness. An ambulance took Resident #1 to the hospital. She stated that Resident #1 was eating sliced beef, 45.e. On 5/17/2012 at 2:00 PM, the Agency’s surveyor conducted an interview with Respondent’ s Administrator, Respondent's administrator admitted to the Agency's surveyor that that Resident #1 was eating regular consistency food on 1/29/2012, when Resident #1 began choking on the meat he was eating.- The Administrator stated to the Agency’s surveyor that the food given to Resident #1 was not of a pureed consistency because Page 20 of 58 Resident #1 was never on a pureed diet since he dia not have any problems eating. The Administrator was not aware that Respondent’ s records for Resident #1 contained a ; physician's order for a pureed consistency diet to be given to Resident #1. Respondent’s Administrator stated’ meat is now tenderized longer. 45.f£. On 5/18/2012 at 10:00 AM, the Agency’s surveyor interviewed the primary physician for Resident #1. The physician told the Agency’s surveyor that he had not changed the diet consistency order for Resident #1. The physician stated that the order from 10/14/2011 for pureed _ consistency diet was still to be followed, as he had not changed the order to a regular consistency. ; 46. The Agency’s surveyor reviewed Resident #11's record and found a health assessment dated 04/11/2012, which stated that the resident was to have a pureed diet. | 46.a. Review of Resident #11's health assessment dated 9/20/2011 revealed the resident was to be on a calorie controlled and pureed diet. 46.b. Review of the Medical Certification for Nursing Facility Home and Community Based Services Form revealed it t i | | was filled out by the facility staff. Further review of this document revealed the staff checked that the resident required a pureed diet. Page 21 of 58 that 47. The Agency’s surveyor reviewed Respondent’s records for Resident #12. 47a. Respondent’s records revealed that Resident #12 “had a health assessment dated 3/28/2012. Further review of the health assessment revealed that the resident is to be on a 2,000 calorie and ADA, diabetic, diet. 47.6. Review of a prior health assessment, dated 12/26/2011, revealed that Resident 412 was to be on a 2,000 calorie and ADA diet. A4T.c. However, when the Agency’s surveyor reviewed a list of residents provided to the Agency's surveyor by the’ Respondent listing each resident receiving a diabetic diet, the list did not include Resident #12's name. 48, The Agency’s surveyor’s review of Resident. #23's . Yecord revealed a health assessment dated 08/15/2011. Review of this health assessment revealed that the resident was to be on a 2,000 calorie, diabetic diet. However, the Agency’s surveyor’s review of the facility's list of people on diabetic diets did not reveal Resident #23's name. 49. The Agency’s surveyor’s review of Resident #25's record revealed a health assessment dated 05/13/2010. The health assessment indicated that the resident is to be on a mechanical soft diet. Review of Resident #25's Resident Observation Log revealed the resident is under HOSPICE care. Page 22 of 58 en aN NS 50. The Agency’s surveyor reviewed Respondent’s records for Resident #26. Resident #26's record contains a health assessment dated 10/31/2011 which indicates the resident is on a regular, low fat/low cholesterol diet with no concentrated . Sweets. However, the Respondent's list of residents on a diabetic diet included Resident #26's name, ' 51. Review of resident #29's record revealed a health assessment dated 10/25/2011. Review of this health assessment revealed the resident was to be on a no-added-salt diet. 52. The Agency’s surveyors interviewed Respondent’s food service staff regarding Respondent’s provision of therapeutic diets, On 5/17/2012 at 1:10 PM, the Agency’s surveyor conducted an interview with Respondent’s Resident Caregiver and Kitchen Aide, who has been at the Respondent's facility since 2005. She stated that pureed or ground-up food is offered if doctor orders are given for that type of food. On 05/18/2012 at 3:55 PM, the Agency's surveyor requested Respondent’s cook to provide a. list of all the specialty diets the facility is currently serving. The cook provided a list that only included 12 residents who were on diabetic diets. The cook was asked if there were any other special diets currently being served to residents, and she replied only diabetic ones. 53. Respondent violated Rules 58A~-5.0182 and 58A-5.020, Florida Administrative Code, by failing to provide therapeutic Page 23 of 58 a a diets as ordered by each Resident’s health care provider. Specifically, Resident #1 was not. given a pureed diet and died of aspiration, sucking in of food particles into the lungs; Resident: #2 was not given a mechanical soft diet; Resident #11 was not given a pureed diet; Resident #12 was not on the list to receive a diabetic diet, and there was no provision to limit caloric intake to 2,000 calories; Resident #23 was not on the list to receive a diabetic diet, and there was no provision to ' limit caloric intake to 2,000 calories; Resident #25 was not given a mechanical soft diet; Resident #26 was given a diabetic diet instead of the ordered low fat/low cholesterol diet with no concentrated sweets; and there was no provision for Resident #29 to be given a no-salt-added diet. . 54. The Agency determined that the above violations as found at the May 17 through 20, 2012, Agency survey are each conditions or occurrences related to the operation and maintenance of a provider or to the care of residents each of which the agency determined presents an imminent danger to the residents of the provider or a substantial probability that death or serious physical or emotional harm would result from the violations, and each of which the Agency determines to be a class I violation for purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative Page 24 of 58 ‘fine in the amount of $6,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described ‘ class I violations found at the May 17 through 20, 2012, Agency survey, pursuant to Chapters 408,-Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. “count IV A029 55. The Agency re-alleges and incorporates paragraphs 1 through 8, as if fully set forth in this count. 56. Rule 58A-5.0182(5), Florida Administrative Code, . requires: (5) NURSING SERVICES. ; (a) Pursuant to Section 429.255, F.S., the facility may employ or contract with a nurse to: 1. Take or supervise the taking of vital signs; 2, Manage pill-organizers and administer medications as described under Rule S8A-5.0185, F.A.C.; 3. Give prepackaged enemas Pursuant to a physician's order; and 4. Maintain nursing progress notes. 57. Rule 58A~5.0185(4), Florida Administrative Code, requires: (4) MEDICATION ADMINISTRATION. ‘(a) For facilities which provide medication administration a staff member, who is licensed to administer medications, must he available. to administer medications in accordance with a health care provider’s order or prescription label. (b) Unusual reactions or a significant change in the resident’s health or behavior shall be documented in the resident’s record and reported immediately to the resident's health care provider. The contact with the health care provider shall also be documented in the Page 25 of 58 ~ we resident’s record. : (c) Medication administration includes the conducting of any examination or testing such as blood glucose testing or other procedure necessary for the proper administration of medication that the resident cannot conduct himself and that can be performed by licensed 4 oo staff. : 58. Section 429.256, Florida Statutes, defines: (3) Assistance with self-administration of medication includes: (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident. (b) In the presence of the resident, reading the label, opening the container, removing a prescribed amount of medication from the container, and closing the container, (c) Placing an oral dosage in the resident's hand or Placing the dosage in another container and helping the resident by lifting the container to his or her mouth. , (d) Applying topical medications. (e) Returning the medication container to proper storage. i (£) Keeping a record of when a resident receives ; : assistance with self-administration under this section, (4) Assistance with self-administration does not i include: : i (a) Mixing, compounding, converting, or calculating i medication doses, except for measuring a prescribed | amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed. {(b) The preparation of syringes for injection or the administration of medications by any injectable route. (c) Administration of medications through intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube : inserted in a cavity of the body. | (e) Administration of parenteral preparations. . (£) Irrigations or debriding agents used in the treatment of a skin condition. (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be Page 26 of 58 ae given “as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and at the request of a competent resident. (1) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion.on the part of the unlicensed person. 59. During May 17 through May 20, 2012, the Agency * conducted an unannounced monitoring survey of the Respondent. 60. Based on the Agency’s surveyor’s interviews, review of Respondent’ s records and observations, the Agency concluded that the Respondent allowed an unlicensed member of Respondent's staff to crush tablets, and the facility's nurse failed to question the order of crushing extended release medications for 2 residents, Residents #15 and #18, of 42 residents whose care. was reviewed. ' 61. On 05/18/2012 at 5:01 PM, the Agency's surveyor interviewed Respondent’s Medication Technician (“Med Tech”) who told the Agency's Surveyor that Resident #15 receives her . medication crushed and put in apple sauce by the Med Tech because Resident #15 has difficulty swallowing. 62. Respondent's Med Tech is not a licensed member of Respondent’s staff. . 63. On 05/20/2012 at approximately 12:05 PM, the Agency’s surveyor again interviewed the Med Tech who told the Agency's surveyor that he only. crushes medications with orders. The Med Page 27 of 58 Tech stated that he was not sure why Resident #18 had. an order for crushed medications. 64, Review of Resident #15's record revealed an order for _exushed medications signed by the resident's physician. Review of the resident's medications revealed she was taking Lithium Carbonate ER 450 at 8:00 PM, Slow Fe 45 Ext-Release Tablet at 8:00 AM, Omeprazole DR 20 milligrams (mg) Cap at 8:00 AM, and Risperidone 2 mg tablet at 8:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM. 65. Review of Resident #18's record revealed an order for crushed medications signed by the same physician as for Resident #15. Further review of the resident's record revealed the resident was taking Januvia 100 mg tablet, which.is also an extended release medication. 66. On Monday 5/21/2012 at 5:05 PM, the Agency’s surveyor interviewed Resident #15's and #18's physician, who confirmed ; that he did tell the Respondent facility that they could crush -the residents' medications. The Agency’s surveyor read the names of the extended release medications to the physician. ‘the physician stated, "You are right, I am going Wednesday [to the facility] and I will clarify them. Some medications should not be crushed if they are extended release." The physician further ‘stated that he would call the facility immediately and instruct them not to crush those medications. Page 28 of 58 67. The Agency determined that the above violations are each conditions or occurrences related to the operation and maintenance of a provider or to the care of residents each of which the agency determined presents an imminent danger to the residents of the provider or a substantial probability that death or serious physical or emotional harm would result from the violations, and each of which the Agency determines to be a class I violation for Purposes of sections 408.813, 408.815, 429.14 and 229.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class I violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT V_ A052 68. The Agency re-alleges and incorporates paragraphs 1 ; through 8, as if fully set forth in this count. 69. Section 429.256, Florida Statutes, requires: (2) Residents who are capable of self~administering their own medications without assistance shall be encouraged and allowed to do so. However, an unlicensed person may, Consistent with a dispensed prescription’s label or the package directions of an over-the-counter medication, assist a resident whose condition is medically stable with the self-administration of routine, regularly scheduled medications that are intended to be self-administered. Assistance with self- Page 29 of 58 medication by an-unlicensed person may occur only upon a documented request by, and the written informed consent of, a resident or the resident's surrogate, guardian, or attorney in fact. For the purposes of this section, self-administered medications include both legend and over-the-counter oral dosage forms, topical dosage forms and topical ophthalmic, otic, and nasal dosage forms including solutions, suspensions, sprays, and inhalers. © (3) Assistance with self-administration of medication includes: (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident. (b) In-thé presence of the resident, reading the label, . opening the container, removing a prescribed amount of medication from the container, and closing the container. : (c) Placing an oral dosage in the resident’s hand or placing the dosage in another container and helping the resident by lifting the container to his or her mouth. (a) Applying topical medications. (e) Returning the medication container to proper storage. . (f) Keeping a record of when a resident receives assistance with self-administration under this section. (4) Assistance with self-administration does not include: (a) Mixing, compounding, converting, or calculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed. (bo) The preparation of syringes for injection or the administration of medications by any injectable route. (c) Administration of medications through intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube ' inserted in a cavity of the body. (e) Administration of parenteral preparations. (f) Irrigations or debriding agents used in the treatment of a skin condition. (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be given “as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and at the request of a Page 30 of 58 competent resident, (1) Medications for which the time of administration, the amount, the ‘strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unlicensed person. 70. Rule 58A-5.0185, Florida Administrative Code, requires: (3) ASSISTANCE WITH SELF-ADMINISTRATION. ; (a) For facilities which provide assistance with self- administered medication, either: a nurse; or an unlicensed staff member, who is at least 18 years old, trained to assist with self-administered medication in accordance with Rule 58A-5.0191, F.A.C., and able to demonstrate to the administrator the ability to accurately read and interpret a prescription label, must be available to assist residents with self- administered medications in accordance with procedures described in Section 429.256, F.S. (ob) Assistance with self-administration of medication includes verbally prompting a resident to take medications as prescribed, retrieving and opening a properly labeled medication container, and providing assistance as specified in Section 429.256(3), F.S. In order to facilitate assistance with self- administration, staff may prepare and make available such items as water, juice, cups, and spoons. Staff may also return unused doses to the medication container. Medication, which appears to have been contaminated, shall not be returned to the container. (c) Staff shall observe the resident take the medication. Any concerns about the resident's reaction to the medication shall be reported to the resident's health care provider and documented in the resident's record. ; (d) When a resident who receives assistance with medication is away from the facility and from facility staff, the following options are available to enable the resident to take medication as prescribed: 1. The health care provider may prescribe a medication schedule which coincides with the resident's presence in the facility; 2. The medication container may be given to the resident or a friend or family member upon leaving the facility, with this fact noted in the resident's Page 31 of 58 ~~ medication record; 3. The medication may be transferred to a pill organizer pursuant to the requirements of subsection (2), and given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record; or ‘4, Medications may be separately prescribed and ; dispensed in an easier to use form, such as unit dose packaging; 7 (e) Pursuant to Section, 429.256(4) (h), F.S., the term “competent resident” means that the resident is cognizant of when a medication is required and understands the purpose for taking the medication. (£) Pursuant to Section 429.256(4) (i), F.S., the terms “judgment” and “discretion” mean interpreting vital signs and evaluating or assessing a resident's condition, (5) MEDICATION RECORDS. (a) wo. (b) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident's health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication .as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. (7) MEDICATION LABELING AND ORDERS. (c) If the directions for use are “as needed” or “as directed,” the health care provider shall be contacted and requested to provide revised instructions. For an “as needed” prescription, the circumstances under which it would be appropriate for the resident to request the medication and any limitations shall be’ specified; for example, “as needed for pain, not to exceed 4 tablets per day.” The revised instructions, including the date they. were obtained from the health care provider and the signature of the staff who obtained them, shall be noted in the medication, record, or a revised label Page 32 of 58: ee We shall be obtained from the pharmacist. (d) 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 MOR, or obtain a revised label from the pharmacist. (e) A nurse may take a medication order by telephone. Such order must be promptly documented in the resident’s medication observation record, The facility must obtain a written medication order from the health care provider within 10 working days. A faxed copy of a signed order is acceptable. 71. Rule 58A-5.024, Florida Administrative Code, requires: (3) RESIDENT RECORDS. Resident records shall be maintained on the premises and include: (h) For facilities which manage a pill organizer, assist with self-administration of ‘medications or administer medications for a resident, the required medication records maintained pursuant to Rule 58A- 5.0185, F.A.C, 72. On November 23, 2011, the Agency conducted a complaint investigation survey of the Respondent. 73. Based on the Agency’s surveyor’s observations, reviews of Respondent’s records, and interviews, the Agency determined that the Respondent failed to provide each resident with medication as ordered by each resident’s physician and failed to properly assist residents with self-administration of medication, 74, ° The Agency's surveyor’s review of Respondent’s records Page 33 of 58 stink oe for Resident #11 revealed that Resident #11 was prescribed Gabapentin 400 milligrams (mg) capsules; with instructions to take 1 capsule 4 times a day for nerve pain. 74,a, The Gabapetin was noted as discontinued on Respondent’s October 2011 medication observation record (“MOR”) for Resident #11. 74.b. However, Respondent's records for Resident #11 contained a Physician's order, date unknown, changing the medication to Gabapentin 300 mg capsule, with instructions to take 2 capsules by mouth 3 times a day. 74.c. Respondent’s records contained no order discontinuing either dosage of Gabapentin medication. 74.d. Yet, according to the MOR, Resident #11 did not receive Gabapentin 300 mg capsule per physician's order for 20 days, from 11/1/2011 through 11-20-2011. 74,.e. Respondent’s records for Resident #11 contained a “new order’ dated 11-21-2011 for Gabapentin 300 mg, with instruction to take one capsule by mouth every 8 hours, initiated on 11-21-2011. 74.8. The Agency’s surveyor’s review of the October and November 2011 MOR's for Resident #11 also revealed that Temazepam 30 mg, with instructions to take one tablet at bedtime as needed for sleep per physician's order, was instead given twice on 11/8/2011 in error. Page 34 of 58 75. On 11-23-2011 at 3:45-PM, the Agency’s surveyor interviewed Resident #11. Resident #11 stated that she has been out of her Hydrocodone medication for about 2 weeks. She was told by members of Respondent’ s staff that there was none in the medication cart, and she had to wait until the 30th of November to have it filled through the Veteran's Affairs pharmacy. Resident #11 stated to the Agency’s surveyor that she is not sure why there is no Hydrocodone left since she only takes it for “break~through” pain, and there should have been enough left to last her until the 30th. Resident #11 stated that she was in a lot of pain and very upset when she first found out there was © no Hydrocodone available for her. . 76, The Agency’s surveyor’s review of the MOR for Resident #11 revealed that Resident #11 received Hydrocodone/APAP 5/500 . mg on 11-19-2011 and 11-21-2011. However, Resident #11 told the Agency’s surveyor that she did not receive any Hydrocodone on 11-19-2011 and 11-21-2011. 77. The Agency’s surveyor’s observation of the contents of Respondent’s medication cart on 11-23-2011 at 2:15 PM revealed that no Hydrocodone/APAP 5/500 mg was available for Resident #11. 78. On 11-23-2011 at 12 noon, the Agency’s surveyor observed Respondent’s medication assistance/administration by one of Respondent’ s Medical Technicians (“Med Tech”). The Page 35 of 58 eee we we Agency’s surveyor observed that a medication tablet was placed ‘into a medication cup at the medication cart, in the hallway and away from the resident. The medication cup was given to Resident #1, who was sitting at a table in the dining room. The Med Tech walked away from Resident #1 without explaining what medication was to be taken. The Med Tech also did not observe Resident #1 taking the medication. 79. As the Agency’s surveyor continued to further observe and review Respondent’s 12 noon medication assistance/administration by Med Tech, on 11-23-2011, the Agency’s surveyor observed that 8 residents did not receive 11 medication as ordered: 79.a. Resident #13 did not receive Tylenol ER 650 mg 1 tablet at 1:00 PM, and Mycostatin Powdér was not applied topically to abdomen at .12 noon. 79.6. Resident #14 did not receive Simethicone 80 mg 1 chew tablet at 1:00 PM, 79.c. Resident #15 did not receive Tylenol 500 mg 1 tablet at 12 noon. 79.d. Resident #16 did not receive Tylenol 500 mg 2 tablets at 2:00 PM, 79.e. Resident #17 did not receive Tylenol 500 mg 1 tablet at 1:00 PM. 79.f, Resident #18 did not receive Tylenol ER 650 mg 1 Page 36.of 58 tablet at 1:00 PM. 79.q. Resident #12 did not receive Buspar 10 mg 1 tablet at 12 noon. 79,h. Resident #19 did not receive Guaifenesin 100 mg/5 milliliters at. 12 noon. 80. The Agency's surveyor’ s review of Respondent’s “narcotics log, controlled substance count, revealed medication count discrepancies as follows: 80.a. Hydrocodone/APAP count on hand = 18; sign out 80.b. Lyrica count on hand = 6: sign out sheet = 15 80.c. Ativan count on hand = 52; sign out sheet = 53 81. On 11-23-2011 at 1:30 PM, the Agency’s surveyor interviewed Med Tech. The Agency’s surveyor was told that Med Tech has been working at this facility for approximately 2 weeks, and he does not know the residents by name. Med Tech stated that he gives out the medications to the residents without supervision. Med Tech stated-he is aware of the discrepancies in the controlled substance medication counts, but does not know how they happened. Med Tech stated he did not count the controlled substance medications that morning when he first arrived for his shift, because there is no medication technician working during the night shift. 82. On 11-23-2011 at 2:00 PM, a second Agency Surveyor Page 37 of 58 observed that Med Tech appeared very confused by routine questions asked in a clear, straight-forward manner. Med Tech did not appear to understand where controlled substance medications were stored until directed by Respondent’s Administrator. Med Tech appeared confused by what and where the medication is which he was asked to locate. Respondent’s Administrator was constantly stepping forward to show him medications and converse with him in another language. Respondent’s Noon Medication Assistance was completed at 2:20 PM. 83. The Agency’s surveyor’s review of the Medication Observation Record (“MOR”) for Resident #18 revealed that BD Insulin U100 % milliliter (ml), “use as directed,” and Lantus 100U/ml inject 13 units subcutaneous every day, are being administered, injected, by a Medication Technician, not a nurse, and the MOR is signed by an unknown member of Respondent’s staff. 84. In an interview on 11-23-2011 at 3:05 pm with resident #9, the Agency’s surveyor was told, "My insulin injections are done by the head guy.” 85, The “head guy” was identified to the Agency’ s surveyor as being the owner of Respondent, who is a Registered Nurse. 86. Respondent’ s failure to provide each resident with medication as ordered by each resident’s physician and failure Page 38 of 58 to properly assist each resident with self-administration of medication are conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the Agency has determined present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm will result from Respondent’s failures, a Class I violation, pursuant to § 408.813, Florida Statutes. 87. On November 30 and December 1, 2011, the Agency conducted another complaint investigation survey of the Respondent. 88. Based on the Agency’s surveyor’s interviews and review of Respondent's records, the Agency determined that the Respondent failed to observe one resident, Resident #2, during assistance with medication, of the two residents whose care was reviewed by the Agency’s surveyor. Respondent’s failure resulted in Resident #2 carrying nine (9) medications in his wallet, 89. When interviewed on 12-01-2011 at 11:00 am, Respondent’ s administrator told the Agency surveyor that he is not aware of any resident not taking medication as ordered. Respondent’s administrator stated that he is aware that Resident #2 had behavior problems in the past, but he has been fine lately. Page 39 of 58 90. Respondent's records for Resident #2 reveal that Resident #2 was admitted to the facility on 9-19-2006. 91. Respondent’ s Medication Observation Record (“MOR”) for Resident #2 has been initialed to indicate that all medications during October 2011 and November 2011 had been taken by Resident #2. 92. Respondent’s Resident Observation Log note dated 8-18- 2011 noted that. Resident #2's case worker reported that Resident #2 showed her several pills that Resident #2 had not taken. Resident #2 claimed the pills were rat poison, and that the President of the United States asked Respondent’s staff to poison him, Resident #2's physician was noted to be aware of Resident #2's behavior. No documentation was noted for a . psychiatric evaluation of Resident #2. Resident Observation Log note dated 9-12-2011 revealed that Resident #2 was taking his medication one at a time, and that Respondent’s staff had been watching him while he took his medication. 93. On 12-01-2011 at 12:30 PM, the Agency’s surveyor interviewed Resident #2. Resident #2 stated that he feels safe at this time but it depends who is giving out medications. Resident #2 believes that staff had been trying to poison him, and that the President was telling Respondent’ s staff to poison him. Resident #2 showed the Agency's surveyor that he had nine (9) pills in his wallet “to prove that they are poison.” Page 40 of 58 wide se Resident #2 took the pills out of his wallet. The pills were identified and destroyed. 94. The Agency determined that Respondent's failure to have. and maintain a complete and accurate medication administration record for each resident receiving medications and to observe each resident during self~administration are conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. 95. On February 3, 2012, an unannounced monitoring survey was conducted of the Respondent. 96. Based on the Agency’s surveyor’s review of Respondent’s records and interviews, the Agency determined that the Respondent failed to ensure proper orders for medications for 5 residents - Residents #2, #3, #4, #5 and #6 -- of 39 residents whose care was reviewed. The Respondent also failed to follow physician’s orders for medication for 1 resident, Resident #7. 97. When the Agency’s surveyor reviewed the Medication Observation Record (“MOR”) for Resident #2, the MOR indicated that the resident has an “as-needed” (“PRN”) order for Page 41 of 58 ~~ ~e Hydroxyzine HCL 10 mg Tablet: “Take 1 Tablet by mouth twice a day as needed, Dx. Anxiety.” There were no orders clarifying the appropriate “as-needed” circumstances for the resident to take the medication. 98. When the Agency's surveyor reviewed the MOR for Resident #3, the MOR indicated a PRN order for Tussin1l00 mg/5 ml liquid, Generic for Iophen NR Lig PT Ambr/Raspby: “Take 5 ml by mouth every 4 hours as needed.” There was no diagnosis listed, or why to. take the medication, nor were the parameters of “as- needed” clarified. 99. Both Residents #2 and #3 reside in the secure unit for Alzheimer’s patients. 100. The Agency’s surveyor'’s review of the Medication Observation Records (°MOR”) for Resident #4 revealed that the resident has diagnosis of DM, Alzheimer's, PUD, Urinary Incontinence and has PRN orders for APAP arthritis Pain 650 Ext- Release Tablet: “Take 1 tablet by mouth every 4 hours as needed.” No diagnosis listed or reason for taking the medication, nor were the parameters of “as-needed” clarified. 101. The Agency’s surveyor’s review of the Medication Observation Records (MOR) for Resident #5 revealed that the resident has diagnosis of Advanced Dementia, Depression, HTN, Hx of Psychosis. Resident #5 has PRN orders for the following medications - APAP 650 mg Suppo 12 CLA, use 1 suppository per Page 42 of 58 ae rectum every 4 hours as needed for mild pain or fever - APAP - Arthritis Pain 650 mg Ext-Release Tablet, Take 1 tablet by mouth every 4 hours as needed for pain - Lorazepam 1 mg Tablet (Generic for Ativan 1 mg tablets), Take 1 tablet by mouth or crushed under tongue every 4 hours as needed for restlessness. However, Respondent's records did not contain a clarifying orders for these medications such as the maximum number of pills to be taken within 24 hours.. 102. The Agency’s surveyor’ s review of the Medication Observation Records (MOR) for Resident #6 revealed that the resident has diagnosis of Dementia and Chronic Kidney Disease. Resident #6 has PRN orders for Albuterol Sulfate 0.083 ml solution (Generic for Proventil 0.083 ml solution), 1 vial 3 times a day via nebulizer as needed for Dysnea. However, Respondent's records do not contain a clarifying order for any of these medications such as the maximum daily dosage. 103. The Agency’ s surveyor’s review of the Medication Observation Records (MOR) for Resident #7 revealed that the ‘resident has diagnosis of Pancreatitis, DM, Atrial FPibrilation, COPD, HTN and CRF. Resident #7 has medication orders for Cyanocobalamin 1000 (Generic for Cobal 1000 mcg/ml injection), Inject 1 ml intra-muscular every month [to be administered by SHC {home care}] - the record indicates that the medication has been given. However, the initials on the MOR are those of Page 43 of 58 ee rd employee #4, an unlicensed person. 104. On 2/3/12 at 12:50 PM, the Agency's surveyor interviewed Respondent’s employee #1, who confirmed PRN (as needed) medications listed for.residents having Dementia, Alzheimer's diagnosis as well as the MOR indicating the’ additional dosages of medication given to Resident #7. 105. The Agency determined that Respondent’s medication ‘administration violations identified during the Agency’ s February 3, 2012, “survey are conditions or occurrences related - to the operation and maintenance of a provider or to the care of residents which the agency determined directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408, 815, 429,14 and.429,19, Florida Statutes. 106. On May 17 through May 20, 2012, the Agency conducted an unannounced monitoring survey of Respondent. 107, Based on the Agency’s surveyor’s review of Respondent’s records and interviews, the Agency determined that the Respondent failed to follow the correct procedures for assisting in the self-administration of medications for 2 residents - Residents #42 and #12 - of the four residents observed receiving assistance with medications. The medication technicians (“Med Techs”) were unable to demonstrate the ability Page 44 of 58 ~~ yy to accurately read and interpret the prescription labels. 108. On 05/20/2012 at 5:15 PM, the Agency’s surveyor observed the medication technician (“Med Tech”) taking Flexeril 10 milligrams (mg) from a bottle of medication for Resident #42. The Med Tech took a whole tablet from the bottle. The medication - observation record (MOR) indicated that the resident was to take 1/2 tablet (5 mg) twice daily. The Med Tech started toward the resident with an entire tablet in the cup. He was stopped by the surveyor before he gave it and asked if that was the correct amount to give to the resident. He stated, “Yes.” He checked the bottle,.and the MOR and stated it was correct. He looked inside the bottle at the pills and said the pills were cut in half at the pharmacy. In fact the pills were whole. The Med Tech stated he thought that because the bottle stated 1/2 tablet on the label the pharmacy had cut’ the pills in half, 109. A review of the Respondent's records revealed to the Agency’s surveyor that Resident #42 was to receive Flexeril 10 mg tablet 1/2 tablet by mouth two times a ‘day. 110. During lunch Med Tech A took 3 bottles of eye drops to Resident #12 and placed them on the table. The resident did not wash her hands before administering the eye drops. She picked up the Latanoprost 0.05% eye drops and instilled 1 drop in both eyes, holding her head straight up and holding only her bottom lid down. She then picked up the bottle of Brimonidine 0.2% and Page 45 of 58 ad ee instilled 1 drop in each eye holding down the lower lid and holding her head erect. She then immediately instilled the Pilocarpine HCL 1% drops 1 drop in each eye, pulling down on the bottom lid, holding her head erect. 111. The Agency’s surveyor’s review of the eye drops’ instructions revealed: lil.a. The instructions for the Latanoprost are: Space dosing with other ophthalmic drugs at least 5 minutes. 1l1.b. The instructions for the Brimonidine are: Space by at least 5 minutes. 112. The Agency determined that Respondent’s failure to properly assist each resident with self-administration of medications and to observe each resident during self- administration are conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $3,500.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violations observed on May 17 through 20, 2012, Page 46 of 58 pursuant to Chapters 408, Part Il, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT VI A053 113. The Agency re-alleges and incorporates paragraphs 1 through 8, as if fully set forth in this count. 114. On September 22 and 23, 2011, the Agency conducted complaint investigation survey of the Respondent. 115. Section 429.256, Florida Statutes, requires: (2) Residents who are capable of self-administering their own medications without assistance shall be encouraged and allowed to do so. However, an unlicensed person may, consistent with a dispensed prescription’s ‘label or the package directions of an over-the-counter medication, assist a resident whose condition is medically stable with the self-administration of routine, regularly scheduled medications that are intended to be self-administered. Assistance with self- medication by an unlicensed person may occur only upon a documented request by, and the written informed consent of, a resident or the resident's surrogate, guardian, or attorney in fact. For the purposes of this section, self-administered medications include both legend and over-the-counter oral dosage forms, topical dosage forms and topical ophthalmic, otic, and nasal dosage forms including solutions, suspensions, sprays, and inhalers. (3) Assistance with self-administration of medication includes: (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident. (b) In the presence of the resident, reading the label, opening the container, removing a prescribed amount of medication from the container, and closing the container, (c) Placing an oral dosage in the resident’s hand or placing the dosage in another container and helping the resident by lifting the container to his or her mouth. (d) Applying topical medications. Page 47 of 58 (e) Returning the medication container to proper storage. (f) Keeping a record of when a resident receives assistance with self-administration under this section. (4) Assistance with self-administration does not include: (a) Mixing, compounding, converting, or: calculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed. (b) The preparation of syringes for injection or the administration of medications by any injectable route. (¢) Administration of medications through intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube inserted in a cavity of the body. (e) Administration of parenteral preparations. (f) Irrigations or debriding agents used in the treatment of a skin condition, (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be given ‘as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and.at the request of a competent resident. (i) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unlicensed person. 116. Rule 58A-5.0182, Florida Administrative Code, provides: (5S) NURSING SERVICES. (a) Pursuant to Section 429.255, F.S., the facility may employ or contract with a nurse to: 1. Take or supervise the taking of vital signs; 2. Manage pill-organizers and administer medications as described under Rule 58A-5.0185, F.A.C.; 3. Give prepackaged enemas pursuant to a physician’s order; and 4. Maintain nursing progress notes. (b) Pursuant to Section 464.022, F.S., the nursing services listed in paragraph (a) may also be delivered Page 48 of 58 in the facility by family members or friends of the resident provided the family member or friend does not receive compensation for such services. 117. Rule 58A-5.0185, Florida Administrative Code, requires: (4) MEDICATION ADMINISTRATION. (a) For facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a health care provider's order or prescription label. : (b) Unusual reactions or a significant change in the resident’s health or behavior shall be documented in the resident’s record and reported immediately to the resident’s health care provider. The contact with the health care provider shall also be documented in the resident’s record. (c) Medication administration includes the conducting of any examination or testing such as blood glucose testing or other procedure necessary for the proper administration of medication that the resident cannot conduct himself and that can be performed ‘by licensed staff. 118. Based on the Agency’s surveyor’s observations, reviews of Respondent’ s records, and interviews, the Agency determined that the Respondent failed to have licensed personnel provide administration of injectable medications for 2 of 16 residents, Residents #4 and #14, 119. On 9/22/2011 at 12:00 PM, at 1:00 PM and at 1:30 PM, the Agency’s surveyor observed that Respondent’s unlicensed medication technicians were preparing to administer insulin to residents who were incapable of self-administering the injections. 120. The Agency’s surveyor’s review of the medical records Page 49 of 58 for Residents #4 and #14, showed a failure to document administration of insulin, including dates and times of insulin injections for the two residents. 121. On 9/22/2011 at 2:00 PM, the Agency's surveyor observed the owner of Respondent, who is a Registered Nurse (RN). The owner did not know where the insulin administered to Respondent’ s vesidents was stored, but Respondent’ s Administrator showed him where it was. 122, The Agency’s surveyor conducted an interview with ' Respondent’s Administrator on 9/22/2011 at 3:00 PM. The Administrator told the Agency’s surveyor that a terminated Assistant Administrator, who was a Certified Nursing Assistant, formerly provided the insulin injections, until 9/13/2011. ‘The owner of the facility is a Registered Nurse (“RN”), but on September 14, 15, 16, 17, 18, 19, 20 and 21, 2011, other employees of respondent who are not licensed professionals -provided the residents with their insulin shots. The . Administrator admitted knowing the limitations of unlicensed staff and medications. ) 123. The Agency determined that Respondent’s allowing unlicensed professionals to administer injectable medications to residents is a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threatens the physical or Page 50 of 58 emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. 124. On May 17 through 20, 2012, the Agency conducted an unannounced monitoring survey of the Respondent. 125. Based on the Agency's surveyor’s review of Respondent’s records and on interviews, the Agency determined that the Respondent failed to ensure that 3 of 42 residents - Residents #23, #27, and #29 -- received medication administration by licensed staff. 126. The Agency’s surveyor’s review of Respondent's records for Resident #23's found a health assessment dated 08/15/2011. According to this health assessment, Resident #23 requires medication administration. 127. The Agency's surveyor reviewed Respondent’s records for Resident #27, finding a health assessment dated 11/13/2011. 127.a. According to the health assessment, Resident #27 requires her medications to be administered to her: "Section 3: Services Offered or Arranged by the facility for the resident," section of the health assessment, under the "Needs Identified Column" appear the words "oral medication." Under the column "Services Needed,” the form indicated that the medications required, "Supervision." Page 51 of 58 i - = ens een ~~ ~~ Under the column for "Services Provider Name" appeared the words “med tech,” indicating that the medications would be supervised by Respondent's medication technician. 127.5, The Agency’s surveyor reviewed Respondent’ s medication observation record (MOR) for Resident #27. The MOR indicated that Resident #27 was to receive Novolin N, with instructions to inject 30 units under the skin every morning. According to the MOR, this is being done by the Hospice Nurse. This was confirmed by the Agency's surveyor’ s review of the Hospice Plan of Care for Resident #27, dated 03/23/2012 ~ 05/21/2012, which states that ‘Hospice will administer intramuscularly or subcutaneous medications to Resident #27. However, upon further review ‘of the Hospice Plan of Care, the Agency’s surveyor found that the Hospice Plan of Care failed to state that Hospice would provide the resident with oral medications. ‘127.0. According to Resident #27's record, the resident's diagnoses are hypertension, hypothyroidism, dementia, Parkinson's disease, and hyperlipidemia. 127.da. The Agency's surveyor conducted an interview with the Respondent's Administrator on 05/19/2012 at 1:10 PM. The Agency’s surveyor was told that the facility provides Resident #27 with her oral medications, and Hospice takes care of the insulin injections. The Agency’s surveyor ‘Page 52 of 58 pointed out to the Respondent’s Administrator that Resident 4 #27's health assessment states that Resident #27 is to | receive administration of oral medication, but the Administrator indicating not being aware that the health “assessment called for medication administration. 128. The Agency's surveyor reviewed Respondent’s records for Resident #29, finding a health assessment form dated 10/25/2011. 128.a. Resident 429" s health assessment indicated that the resident required administration of her medication. Review of "Section 3: Services offered or arranged by the facility for the resident," of the health assessment revealed under the column "Needs Identified," that Resident #29 had a need for medication, Under the column for "Services Needed," it stated that Resident #29 needed "Supervision" with her medication.. 128.b. Review of Resident #29's 5/1/2012-5/31/2012 MORs revealed that up until the 8:00 AM dosage on 08/19/2012, the facility has been providing the resident with her medications. According to the resident's records, her diagnoses are acute GI bleed, history of urinary tract : infection (UTI), protein cal. Malnutrition, hypophosphatemia, advanced dementia, crohn disease, cardiovascular accident, osteoporosis, and vitamin D : ‘ Page 53 of 58 deficiency. 128.c. On 05/19/2012 at 1:10 PM, the Agency’s surveyor interviewed Respondent’s Administrator. Respondent's Administrator told the Agency’s surveyor that the Respondent’ s facility staff has been providing Resident #29 with her medications. Resident #29's health assessment was shown to the Administrator and he indicated not knowing that it stated the resident required medication administration. 129. The Agency determined that Respondent’s failure to provide residents needing medication administration with medication administration by a licensed person is a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the Agency determined directly threatens the physical or emotional health, safety, or ' security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429,14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violation identified during the May 17 through 20, 2012, Agency survey, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this Page 54 of 58 tribunal deems just. COUNT VII A092 130. The Agency re-alleges and incorporates paragraphs 1 through 8, paragraph 32, and paragraphs 42 through 57, as if fully set forth in this count. 131. On May 17 through 20, 2012, the Agency conducted an unannounced monitoring survey of the Respondent. 132, Based on the Agency’s surveyor’s review of Respondent’s records and on interviews, the Agency determined that the Respondent failed to provide therapeutic diets to each resident as ordered by each resident’s health care provider. 133. The Agency determined that the above violations as found at the May 17 through 20, 2012, Agency survey are each conditions or occurrences related to the operation and maintenance of a provider or to the care of residents each of which the agency determined presents an imminent danger to the residents of the provider or a substantial probability that death or serious physical or emotional harm would result from ‘the violations, and each of which the Agency determines to bea class I violation for purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described Page 55 of 58 class I violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT VIII REVOCATION 134, The Agency re~alleges and incorporates paragraphs 1 through 8, as if fully set forth in this count. 135. Counts I, Il, V and VI are three are more cited class II deficiencies for purposes of § 429.14 (1) (e), Florida Statutes, and warrant revocation of Respondent’s license. 136. Counts ttt, IV, and VII are each cited class I deficiencies, for purposes of § 429.14(1) (e), Florida Statutes, ‘and each warrants revocation of Respondent’s license. 137. Counts I through VII show a demonstrated pattern of deficient performance for purposes of § 408.815(1)(d), Florida Statutes, warranting revocation of Respondent’s license. 138. Counts II and III show a demonstrated pattern of: deficient performance for purposes of § 408.815(1) (d), Florida statutes, in failing to provide Respondent’s residents with therapeutic diets as ordered by each resident's health care provider, warranting revocation of Respondent’s license. 139. Count V shows a demonstrated pattern of deficient performance for purposes of § 408.815(1) (d), Florida Statutes, over the Agency’s surveys from November 23, 2011, through May 20, 2012, warranting revocation of Respondent’s license. Page 56 of 58 ee ere aed er 140. Count VI shows a demonstrated pattern of deficient performance for purposes of § 408.815(1) (d}), Florida Statutes, over the Agency’s surveys from September 22, 2011, through May 20, 2012, warranting revocation of Respondent's license 141. Each of Counts I through VII are a violation of this part, authorizing statutes, or applicable rules, for purposes of § 408.815(1) (c), Florida Statutes. 142. Each of Counts I through VII are an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility, for purposes of §§ 408.815(1) (b) - and 429.14(1) (a), Florida Statutes, each warranting revocation of Respondent’s license. 143. Bach of paragraphs 135 through 142 are a separate and distinct ground for revocation of Respondent's license as an assisted living facility. 144. Taken together, paragraphs 135 through 142 show a further demonstrated pattern of deficient performance for purposes of § 408.815(1) (da), Florida Statutes, warranting revocation of Respondent's license as an assisted living facility. WHEREFORE, the Agency intends to revoke the license of Respondent, an assisted living facility in the State of Florida, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. Page 57 of 58 NOTICE 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 FBlection 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, whose telephone number is 850-412-3630. ’ RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. , CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No, 7210-07-86 -900|~4636~2%3 to Miskel Ortiz, Administrator, ' 507 S.E. 1° Avenue, Williston, FL 32696, and by regular U.S. Mail to Gus R. Benitez, Esq., as attorney for Andrada Sunshine ‘Corp., 1223 East Concord Street, Orlando, FL 32803, on wwe , 2012. a es H. Harris istant General Counsel Fla. Bar. No. 817775 Agency for Health Care Admin. 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 727-552-1944 (office) 727-552-1440 (facsimile) Copies furnished to: Anna Lopez, HFE Supervisor, Alachua Page 58 of 58 ) ) STATE OF FLORIDA / AGENCY FOR HEALTH CARE ADMINISTRATION RE: Andrada Sunshine Corporation d/b/a CASE NO. 2012005708 Good Samaritan Retirement Home ELECTI F RIGHT: This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Lnpose a Late Fine or Administrative Complaint. Your Electio 1 ints must retu b il_or by fax ithin 21 d f the da ece e attache i f Intent t pose a Late Fee, Notice of Inten € or inistrati' maplaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax; 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1). I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing, I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2)___—s—is« admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative . Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), - Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)_____I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing, You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. Tt must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone nutaber of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. ; Mediation. under Section 120,573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: i Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above, Signed: Date: Print Name: Title: Late fee/fine/AC USPS.com® - Track & Confirm English Customer fervice USPS Mobile BaUSPS.COM’ Quick Tools Ship a Package Send Mail Manage Your Mall Track & Confirm QUTBNAIL UPDATES «—-PRINY DETAILS ' ‘YOUR LABEL NUMBER . SERVICE STATUS OF YOURITEM DATE & ME 70100780000108362763 Dalvered Jone 11, 2012, $38 pm _ Astival at Unit” * dune £1, 2012, 7:33 em i . + Depart USPS Sort duno 10, 2012 . . Fackity Processed through sno 09, 2012, 7:64 pm. USPS Sort Facility * Check on Another item ‘Whats your taba (oF receipt) number? Find LEGAL ON USPS.COM ‘ON ABQUT.USPS.COM Privacy Polley > Goverment Services > About USPS Home > Terms of Use > Buy Stamps & Shop » . Newsroon > FOWy Panta Label with Postage > Mail Service Updates > No FEAR Act EEO Data > Customer Service » Forms & Publications > Site Index > Careers > Copyright® 2012 USPS. AN Rights Reserved. https://tools.usps.com/go/TrackC onfirmAction.action Page 1 of 1 Register 28ign In Search USPS.com or Track Packages Shop Business Solutions LOCATION . FEATURES WILUBTON, FL 32808 Certified Meil™ WILLISTON, FL 32605 JACKSONVILLE, FL 32009 | _ MACKSONVILLE, FL 32099 OTHER USPS SITES Business Customer Gateway » Postal Inspactors > Inspector General > Postal Explorer > 06/26/2012

Docket for Case No: 12-002272