(psres” STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003006692 Return Receipt Requested: Vv. 7000 1670 0011 4849 4712 7000 1670 0011 4849 4729 CREST MANOR ASSISTED LIVING, L.C. 7000 1670 0011 4848 6533 d/b/a CREST MANOR, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this administrative complaint against Crest Manor Assisted Living, L.C. d/b/a Crest Manor (hereinafter “Crest Manor” or the “facility”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2002) (“Fla. Stat.”), and alleges: NATURE OF THE ACTION 1. This is an action to impose and maintain the Agency’s administrative fine of $1,000.00, pursuant to Sections 400.414 and 400.419, Fla. Stat., for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28-106, Florida Administrative Code. 3. Venue lies in Palm Beach County pursuant to Section 120.57 Florida Statutes, Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part III, Florida Statutes (2002) and Chapter 58A-5 Florida Administrative Code. 5. Crest Manor operates a 52-bed assisted living facility located at 504 Third Avenue South, Lake Worth, Florida 33460. Crest Manor is licensed as an assisted living facility under license number 10028. Crest Manor was at alli times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I CREST MANOR FAILED TO MAKE EVERY REASONABLE EFFORT TO ENSURE THAT PRESCRIPTIONS FOR RESIDENTS WHO RECEIVE ASSISTANCE WITH MEDICATIONS ARE REFILLED IN A TIMELY MANNER. RULE 58A-5.0185(7) (£), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) UNCORRECTED CLASS III VIOLATION 6, AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. The Agency cited Crest Manor with one (1) uncorrected Class III violation pursuant to Change Of Ownership licensure surveys conducted on February 25, 2003 and August 26, 2003. 8. Based on the survey conducted by the Agency on February 25, 2003 and based on record review and interview, the Agency found that Crest Manor failed to make every reasonable effort to ensure that prescriptions for residents who receive assistance with medications are refilled in a timely manner. The Agency found that the facility failed to ensure that a prescription was available for 3 out of 6 residents who all received assistance with medication. The findings include the following, to wit: 9. During the Agency’s surveyor’s review of Resident #1's MOR (Medication Observation Record), it was revealed that the resident was ordered Centrum tablets, 1 tab to be given once per day. Upon the process of medication review with the facility's medication technician, the medication was not available. The technician was interviewed and stated that the resident ran out of this medication and the prescription had not been refilled as of the day of the survey. 10. During a review of Resident #3's MOR, it was revealed that the resident was ordered Antivert 25 mg, one tab to be given three times per day, as needed, and Tylenol 325 mg, 2 tabs to be given every 4-6 hours for pain and elevated temperature, as needed. During the medication review with the facility's medication technician, the medication was not available. 11. During a review of Resident #5's MOR, it was revealed that the resident was ordered Folic Acid 1 mg, 1 tab to be given once per day, and Tylenol 500 mg, 1 tab to be given every 4-6 hours for pain and elevated temperature, as needed. During an interview, the resident stated that his/her insurance, which covered his/her medication, lapsed approximately one month ago. The resident also reported that he/she had been out of Folic Acid for over one month. During an interview, the Administrator acknowledged that she was aware that Resident #5 no longer had insurance to cover his/her medication, but was unaware that the facility was required to ensure that the resident's prescriptions were refilled in a timely matter, despite his/her financial stability. During the process of the medication review for Resident #5, the medications listed above were also unavailable. 12. The mandated correction date for this Class III violation was designated as March 27, 2003. 13. Based on a survey conducted by the Agency on August 26, 2003 and based on record review and interview, the Agency again found that Crest Manor failed to make every reasonable effort to ensure that prescriptions for residents who receive assistance with medications are refilled in a timely manner. The Agency found that the facility failed to ensure’ that prescriptions were refilled in a timely manner for 6 out of 32 residents who all receive assistance with medication. The findings include the following, to wit: 14. During the Agency’s surveyor’s review of Resident #1's current Medication Administration Record (MAR) dated August 2003, it was revealed that the resident was prescribed: Ami-Tex PSE 600/120, 1 tablet to be given twice per day. Further review of Resident #1's MAR documented that from 08/03/03~-08/05/03, a total of 6 doses, the resident did not receive his/her medications, as they were on order from the pharmacy. During record review, it was revealed that the resident suffers with diagnosis of ASHD, DJD and mental retardation. 15. During a review of Resident #2's current MAR dated August 2003, it was revealed that the resident was prescribed 5 Atenolol 25 mg, 1 tab to be given once per day. Further review of the MAR revealed that the resident missed 4 doses of this medication, from 08/01/03-08/04/03. The MAR documented that the Atenolol was on order from the pharmacy. During record review, it was revealed that the resident suffers with diagnosis of Congestive Heart Failure and Dementia. 16. During a review of Resident #3's current MAR dated May 2003, it was revealed that the resident was prescribed Trazadone 150 mg, 1 tablet to be given once per day. Further review of the MAR revealed that on 08/03/03, 08/23/03, and 08/24/03, the resident did not receive this medication; a total of 3 doses. The MAR documented that this medication was on order from the pharmacy. During record review, it was revealed that the resident suffers with diagnosis of Alcohol Dependency Syndrome and Bipolar Disorder. 17. Upon review of Resident #4's current MAR dated August 2003, it was revealed that the resident was prescribed Atenolol 25 mg, one tablet to be given once per day. Further review of the MAR revealed documentation that the resident did not receive this medication on 08/10/03, and from 08/13/03-08/19/03, a total of 8 doses. The MAR also documented that the resident was also prescribed Restoril 15 mg, 1 tablet to be given once per day, as needed. During the medication review with the facility's nurse, it was revealed that medication was not available for review. During the surveyor’s interview with the Administrator and facility nurse, it was revealed that the resident missed this medication because it was on order. During record review it was revealed that the resident suffers with the diagnosis of Hypertension and Bipolar Disorder. 18. During a review of Resident #5's MAR, it was revealed that the resident was prescribed Zyrtec 10 mg, one tab to be given once per day and Omeprazole 20 mg, one tablet to be given once per day. Further review of the MAR revealed documentation that the resident did not receive either medication on 08/11/03, a total of 2 missed doses. During an interview, the Administrator stated that Resident #5's family members are responsible for his/her medications. During record review it was revealed that the resident suffers from the diagnosis of Alzheimer's, Rheumatoid Arthritis and Chronic Anemia. 19. During a review of Resident #6's MAR dated August 2003, it was revealed that the resident was prescribed Lisinopril 10 mg, to be given twice per day, and Coumadin 2 mg, one tab to be given twice per day. Further record review revealed that Resident #6 did not receive his/her Coumadin on 08/25/03, a total of 1 missed dose. Further record review revealed that the resident did not receive his/her Lisinopril on 08/25/03 and 08/26/03, a total of 3 missed doses. During the medication review with the facility nurse, the nurse revealed that this medication was not available for review. Review of the MAR and interview with the nurse revealed that these medications were on order from the pharmacy. 20. During the surveyor’s interview with the Administrator, the Administrator stated that she had no idea that 6 residents missed their medications 1 or more times during the month of August 2003. The Administrator also stated that the facility's contracted pharmacist's last visit to the facility was on 07/15/03, where she conducted a monthly medication review. During record review and a later interview with the Administrator and DON, it was revealed that there were no other efforts attempted to ensure that Resident numbers 1-6 received their medications from alternative sources, nor was there documentation that the residents’ physicians were notified that they missed their prescribed medications. 21. This is an uncorrected violation. 22. Based on the foregoing, Crest Manor violated Rule 58A- 5.0185(7) (£), Florida Administrative Code, herein classified as an uncorrected Class III violation, pursuant to Section 400.419(1) (c), Fla. Stat., which warrants an assessed fine of $1,000.00, CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Crest Manor on Count I. 2. Assess an administrative fine of $1,000.00 against Crest Manor on Count I for the violation cited herein. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration Respectfully submitted, Kathyyn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 142832 8355 N. W. 53 Street Miami, Florida 33166 (305) 499-2165 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 10 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Bonita A. Brody, Administrator, Crest Manor, 504 Third Avenue South, Lake Worth, Florida 33460; Crest Manor Assisted Living, L.c. 2151 N. E. Coachman Road, Clearwater, Florida 33765; David B. Thomas, 2151 N. E. Coachman Road, Clearwater, Florida 33765 on this DX say of , 2003. Fenske, Esq. il

Docket for Case No: 03-003865