rd STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No, 2011008337 J & G FLORIDA ENTERPRISES, L.C., d/b/a SUTTON HOMES #7, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“Agency”) and files this Administrative Complaint against J & G Florida Enterprises, L.C., d/b/a Sutton Homes #7 (“Respondent” or “Respondent Facility”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the sum of five hundred dollars ($500.00) based on ohne State class III deficiency not corrected within the mandatory correction period, pursuant to Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and 429.07, and Chapter 408, Part II, Florida Statutes (2010). * Filed July 5, 2012 11:48 AM Division of Administrative Hearings _ 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207, PARTIES 3. The Agency is the regulatory authority responsible for licensing assisted living facilities and enforcing all applicable state rules and statutes 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 five-bed assisted living facility located at 4055 Lake Forest, Mount Dora, Florida 32757, license number 10362. 5. At all times material to the allegations of this complaint, Respondent was a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I A416 6. The Agency re-alleges and incorporates above paragraphs one (1) through five (5), as if fully set forth in this count. 7. Section 429.02, Florida Statutes, defines: *(19) ‘Resident’ means a person 18 years of age or older, residing in and receiving care from a facility.” 8. Section 429.26, Florida Statutes, requires; (1) The owner or administrator of a facility is respohsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued - residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident’s representative or designee or the resident's family, guardian, surrogate, or attorney in fact. In the case of a resident who has been placed by the department or the Department of Children and Family Services; the administrator must notify the appropriate contact person in the applicable department. (2) A physician, physician assistant, or nurse _ practitioner who is employed by an assisted living facility to provide an initial examination for admission purposes may not have financial interest in the facility. (3) Persons licensed under part I of chapter 464 who are employed by or under contract with a facility shall, on a routine basis or at least monthly, perform a nursing assessment of the residents for whom they are providing nursing services ordered by a physician, except administration of medication, and shall document such assessment, including any substantial changes in a resident’s status which may necessitate relocation to a nursing home, hospital, or specialized health care facility. Such records shall be maintained in the facility for inspection by the agency and shall be forwarded to the resident’s case manager, if applicable. (4) If possible, each resident shall have been examined by a licensed physician, a licensed physician assistant, or a licensed nurse practitioner within 60 days before admission to the facility. The signed and completed medical examination report shall be submitted to the owner or administrator of the facility who shall use the information contained therein to assist in the 7 determination of the appropriateness of the resident’s admission and continued stay in the facility. The medical examination report shall become a permanent part of the record of the resident at the facility and shall be made available to the agency during inspection or upon request. An assessment that has been completed through the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program fulfills the requirements for a medical examination under this subsection and s. 429.07(3) (b)6. (5) Except as provided in s,. 429.07, if a medical . examination has not been completed within 60 days before the admission of the resident to the facility, a licensed physician, licensed physician assistant, or licensed nurse practitioner shall examine the resident and complete a medical examination form provided by the agency within 30 days following the admission to the facility to enable the facility owner or administrator to determine the appropriateness of the admission. The medical examination form shall become a permanent part of the record of the resident at the facility and shail be made available to the agency during inspection by the agency or upon request. 9. Rule 58A~5.0181(2), Florida Administrative Code, requires: (2) HEALTH ASSESSMENT. As part of the admission ‘oriteria, an individual must undergo a face-to-face medical examination completed by a licensed health care provider, as specified in either paragraph (a) or (bk) 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; , 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, ‘gignature, 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. fdhe,. state. fl.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. 10. Rule 58A-5.024(4), Florida Administrative Code, requires: (4) RECORD INSPECTION. (a) All records required by this rule chapter shall be available for inspection at all times by staff of the agency, the department, the district long-term care ombudsman council, and the advocacy center for persons with disabilities. 11. On May 31, 2011, the Agency conducted a biennial licensure survey of the Respondent Facility. 12. Based on the Agency surveyor’s review of Respondent’ s records for four (4) residents and interviews, the Agency determined that Respondent failed to have a completed health assessment for each resident. 213. One resident's, Resident #1’s, record was missing page 2 of the Agency’s Form 1823, including an evaluation of the resident’s ability to perform activities of daily living (YADL's”), whether or not the resident exhibited signs and symptoms of gommunicable disease, and a statement of a health care provider’s opinion as to whether the resident’s needs can be met in an assisted living facility (“BLE”). 14. ‘The Agency’s surveyor conducted an interview with Respondent’s Employee #2 on 5/31/2011 at 11:15 AM. Respondent’s Employee #2 told the Agency’s surveyor that the employee did not know why part of Resident #1's recent health assessment was missing. we ch canna neet nein ee tent 15. The Agency determined that this deficient practice of failing to have a complete health assessment for each resident was related to the personal care of the residents that . indirectly or potentially threatened the health, safety or security of the residents and cited Respondent for a State Class III deficiency. ) 16. The Agency provided Respondent with a mandatory correction date of July 1, 2011. ; 17. On duly 12, 2011, the Agency conducted a revisit to the re-licensure survey of the Respondent facility. 18. Based on the Agency’s surveyor’s observations, review of Respondent’s records and interviews, the Agency determined that the facility still failed to ensure that each resident’s health assessment was complete. 19, Specifically, the agency's surveyor found that for three (3) - Residents #1, #3 and #4 - of Respondent's five (5) residents, Respondent had AHCA Form 1823s, health assessment forms, lacking a complete list of medications that the residents were receiving. 20. The Agency’s surveyor’s review of Respondent’s records for Resident #1 and #3 found health assessments for which Section C, the section for prescribed medication, was not completed by each resident’s physician to document the resident's prescribed medications. There was a note that said, “gee MARS." MARS are medication administration record, and the facility does not usé the medication administration record form. The medication observation records (“MORs”) for each patient were also not attached to either of the residents' health assessments. 21. Review of Resident #4’s health assessment Section C for prescribed medication revealed that the physician completed a clarification for the Temazepam medication and wrote a note "see MARS for remainder.” However, neither MARs nor MORs were attached to the health assessments. 22. ‘The Agency’s surveyor conducted an interview with the Respondent’s acting administrator on 7/12/11 at 11:00 a.m. The acting administrator stated that she was unable to answer any questions because she was not aware of what the administrator had completed before going on vacation. Continued interview revealed that she had placed a call to “the Orlando office” and they were under the impression that the administrator had updated the 1823s. 23. The Agency determined that this deficient practice of failing to have a complete health assessment for each resident was related to the personal care of the residents that indirectly or potentially threatened the health, safety or security of the residents and cited Respondent for a State Class _ LIT deficiency. and 24. The violation identified at the Agency’s survey of May 31, 2011, being uncorrected at the next Agency survey of July 12, 2011, the violation is “uncorrected” for purposes of §§ 408.813 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted ; living facility in the State of Florida, pursuant to §$ 408.813 and 429.19, Florida Statutes, or such further relief as this tribunal deems just. NOTICE OF RIGHTS 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, FI 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 Administrative Complaint and Election of Rights form have been served by U.S. Certified Mail, Return Receipt No. 7003 1010 0001 3600 4415 to Dana Weaver, Administrator, Sutton Home #7, 919 Orange Avenue, Suite 200, Winter Park, Florida 32789, and by regular U.S. Mail to James M. Baxter, Managing Member, J & G Florida Enterprises, L.C., 600 Maiden Lane, Winter Park, : Florida 32789, on May 3j , 2012. Fla. Bar. No. 817775 Assistant General Counsel Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727-552-1944 Facsimile; 727-552-1440 Copies furnished to: Anna Lopez, Alachua 10 ‘Administrator Dana r Sutten Home:#7 :; 919 Orange Avenue i Suite 200 ; Winter Park, Florida 32769

Docket for Case No: 12-002307