)Q-131% STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2001072731 vs. FOREST GLEN LODGES, INC. Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration _— (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Forest Glen Lodges, Inc. (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent in the amount of one thousand dollars ($1000) pursuant to Sections 400.414 (1) (a) and 400.419(1) (b), Florida Statutes. 2. Respondent is cited for the deficiency set forth below as a result of a Survey on or about November 29, 2001. The deficiencies ere Class II deficiencies. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Pasco County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28, Florida Administrative Code. PARTIES 5. AHCA, Agency for Health Care Administration, State of Florida is the enforcing authority with regard to assisted living facility Licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 7435 Plathe Road, New Port Richey, FL 34653. Respondent, is and was a- all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I RESPONDENT FAILED TO ADEQUATELY ASSIST RESIDENTS WITH SELF- ADMINISTRATION OF MEDICATION VIOLATING SECTIONS 400.4256 (3) AND 400.428(1) (a), F.S AND RULE 58A-5.0185(3), F.A.C. CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. Based on record review and interview it was determined that a facility staff member who assisted residents with self-administration of medication gave Resident #1, who is non-diabetic, the medication Glyburide in error. Resident #1 suffered a reaction for which the resident was hospitalized. The facility Medication Error report documented the resident was hospitalized with a diagnosis of hypoglycemia and medication reaction. 9. This is a violation of: (A) Section 400.4256(3), Florida Statutes which requires Respondent to provide assistance with self- administration of medication that includes taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident; 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; 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; (B) Section 400.428(1) (a), Florida Statutes which requires every resident of a facility to have the right to live in a safe and decent living environment, free from abuse and neglect; and (C) Rule 58A-5.0185(3), Florida Administrative Code which requires when Respondent provides 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-administration in accordance with Rule 58A-5.0191, Florida Administrative Code, 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-administration medications in accordance with procedures described in Section 400.4256, Florida Statutes. 10. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of one thousand dollars ($1000) is authorized pursuant to Sections 400.414(1) (a) and 400.419(1) (b), Florida Statutes. 11. Notice was provided in writing to Respondent of the above violation and the time frame for correction. WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order relief with a fine against Respondent pursuant to Sections 400.414(1) (a) and 400.419(1)(b), Florida Statutes in the total amount of one thousand dollars ($1000). Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O’Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr. N., St. Petersburg, Florida, 33701. 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. to Respondent’s Registered Agent by U.S. aed tted “Cet? Eileen O'Hara Garcia, AHCA - Senior Attorney Esquire 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 I HEREBY CERTIFY that a true copy hereof has been sent Certified Mail to Barbara J. Masco, 967 Pine Hill Road, Palm Harbor, FL 34683 Return Receipt No. 7001 2510 0007 5976 5575, aay of March, 2002. bea. Copies furnished to: Barbara J. Masco Eileen O’Hara Gar Registered Agent for Forest Glen Lodge, Inc. 967 Pine Hill Road Palm Harbor, FL 34683 (U.S. Certified Mail) Administrator Forest Glen Lodge, Inc. 7435 Plathe Road New Port Richey, (U.S. Mail) FL 34653 Eileen O’Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive Suite 310J St. Petersburg, Fl 33701 on this the

Docket for Case No: 02-001312