STATE OF FLORIDA ;: m PY AGENCY FOR HEALTH CARE ADMINISTRATION 04 JUN -9 PH &: 13 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, CASE NO: 2004001931 vs. PRIME CARE ONE, LLC, d/b/a BRIGHTON GARDENS OF NAPLES, 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 PRIME CARE ONE, LLC, d/b/a BRIGHTON GARDENS OF NAPLES (hereinafter “Respondent”) and alleges the following: NATURE OF THE ACTION 1. This is an action to impose administrative fines on Respondent pursuant to Section 400.419(1) (c), Florida Statutes (2003). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes (2003) and Chapter 28-106, Florida Administrative Code (2003). 3. AHCA, Agency for Health Care Administration, has jurisdiction over Respondent pursuant to Chapter 400, Part III, Florida Statutes (2003). 4. Venue lies in Collier County, Division of Administrative Hearines, pursuant to Section 120.57, Florida Statutes (2003), and Chapter 28, Florida Administrative Code (2003). PARTIES 5. Agency for Eealth 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 (2003) and Rules 58A-5, Florida Administrative Code (2003). 6. Respondent is an assisted living facility located at 7801 Airport Pulling Road N.E., Naples, FL 34109. Respondent, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code, having been issued license number 9172. COUNT I RESPONDENT FAILED TO MAINTAIN A DAILY, UP-TO-DATE MEDICATION OBSERVATION RECORD FOR RESIDENTS WHO RECEIVE ASSISTANCE WITH SELF-ADMINISTRATION OR MEDICATION ADMINISTRATION. Fla. Admin. Code R.58A-5.0185(5) (b) (2003) REPEAT CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about September 10-11, 2003, a biennial survey was conducted at Respondent’s facility. 9. Based on observation, interviews with staff and resident record review, the facility failed to have a complete, up-to-date and accurate MOR (medication observation record) for residents #3 and #4 (2 of 4 active sampled residents). The findings include: 1. During initial tour of the facility on 9/10/02 at approximately 9:45 a.m. in apartment # 118, a bottle of Advil was observed on the table of resident # 3's unit. The resident had been assessed by the facility as needing assistance with all medications. This medication does not appear on the MOR. Review of the resident record did not indicate knowledge by the facility or the physician that the resident had this medication in her apartment. Review of the Medication Observation Record failed to see any documentation of Advil as being ordered by the physician. Interview with Assisted Living Manager revealed that this medication should be centrally stored, administered and recorded on the MOR. The facility was unable to provide a physician order for this Over-the-counter medication. 2. During initial tour of the facility on 9/10/02 at approximately 9:50 a.m. in apartment # 220, several medications (Afrin nasal spray, Tums, Tylenol and Albuterol) were observed on the table of resident # 4. Along with the medications on the table was a nebulizer. This resident had been assessed by the facility as needing assistance with all medications. These medications do not appear on the MOR. Review of the Medication Observation Record failed to see any documentation of these medications being assisted with. Review of the record failed to contain any documentation of Nebulizer treatments with Albuterol as being ordered by the physician. The record did not contain any documentation regarding Tylenol, Afrin Nasal Spray or Tums. Review of the resident record did not indicate knowledge by the facility that the resident had these medicztions in her apartment or that she was giving her own nebulizer treatments. The Assisted Living Manager who accompanied the surveyor on tour validated this information. She also validated that this medication should be centrally stored, administered and recorded on the MOR. Review of the assessment for this resident indicated that she is to have assistance with all her medications. The facility was unable to provide a physician order for this Over-the-counter medication, nebulizer treatments or the Albuterol used in the nebulizer. The record does contain an order for Albuterol 90mcg inhaler, 2 puffs, TID (three times a day) which the facility assists with administration. Interview with the resident revealed that she has been administering her own treatments, ordering her own medication as well as ordering her own oxygen tanks (refills) without assistance or knowledge of the facility since admission on 4/11/03. 3. Medications were removed from both apartments, after surveyor intervention, until orders can be received and new assessments completed. 10. Respondent was provided a mandated correction date of October 11, 2003. 11. On or about November 3, 2003, a follow-up survey was conducted at Respondent’s facility. At this time, the above- listed deficiency had been corrected. 12. On or about February 16-17, 2004, a change of ownership survey was conducted at Respondent’s facility. 13. Based on medication observation record review, resident record review and interview with staff, the facility failed to maintain an accurate up-to-date medication observation record (MOR) for 4 of 7 (#2, #3, #4 and #5) active residents sampled as evidenced by 1.) Resident #3's MOR stated the resident was receivine "Betadine and Band-Aid to distal amp site every three days until healed" and this order was discontinued when the wound was healed. 2.) Resident #3's MOR stated "Accu- check for blood sugar before breakfast, lunch and dinner hold Humalog if blood sugar below 80", the MOR had missing blood sugars with no explanation. 3.) Resident #5's MOR stated "Nizoral 2% cream apply to face and chest twice daily as needed", the MOR had no documentation the cream was used and observation of the tube of cream revealed it was used. 4.) Resident's #2 and #4 had incomplete MOR's. The findings include: 1. Review of the medications for Resident #3 revealed the resident was on insulin for Diabetes. Review of the resident record revealed the Resident had orders for insulin, Lantus 22 units at bedtime, Humalog 5 units daily 8 AM hold if blood sugar below 80 and Humalog 7 units twice daily at 12 noon and 5 PM. The record also contained an order for Accu-checks for blood sugars before breakfast, lunch and dinner. Review of the MOR revealed the Resident did not have the Humalog 5 units at 8 AM on 2/3 and 2/4/04. Review of the Accu-checks revealed no blood sugars were recorded for 8 AM on 2/2, 2/3, 2/4, 2/5 and 2/17. Further review of the MOR revealed the Resident did not receive Humalog 7 units at 12 noon on 2/1, 2/2, 2/7/ 2/8, and 2/14/04. Review of the Accu-checks revealed no blood sugars were recorded for 12 noon on 2/2, 2/3, 2/6, 2/12, 2/15 and 2/16. The Resident had blood sugars below 80 on 2/7 and 2/8/04 and on this dates staff gave the insulin. Review of the MOR revealed the Resident did not receive Humalog 7 units at 5 PM on 2/4, 2/6, 2/8, 2/9, and 2/10/04. Review of the 5 PM Accu-checks revealed no blood sugars were recorded for 2/3, 2/6, 2/8 and 2/10/04. There is no explanation as to why the insulin was not given or why blood sugars were not taken. Further review of the MOR revealed the Resident was receiving "Betadine and Band-Aid to distal amp site every three days until healed.” This order was dated 1/7/04. Review of the Limited Nursing Service log for February revealed the Resident was not receiving this treatment in February. Further review of the MOR revealed staff were signing the treatment was continued through the month of February. Interview with staff revealed the Resident was not receiving the treatment. 2. Review of the MOR for Resident #5 revealed the Resident was to receive “Nizoral 2% cream apply to face and chest twice daily as needed", the MOR had no documentation the cream was used. Observation of the tube of cream revealed it was used. 3. Review of the MOR's for Resident #2 revealed on 2/13/04 all of the Resident's medication were circled as not given with no explanation on the MOR or in the Resident's record. 4. Review of the MOR's for Resident #4 revealed on 2/3/04 the following medications were circled as not given without explanation; Aspirin 81 mg, Tylenol 1000 mg, Senakot 2 tablets, Multivitamin, Os-Cal with Vitamin D 600 mg and Miralax 17 gms (grams) with 8 ounces of liquid. 5. Interview with the Assisted Living Coordinator on 2/17/04 at approximately 11 AM revealed the Coordinator confirmed the MOR's were inaccurate and not up-to-date. 14. Respondent was provided a mandated correction date of March 17, 2004. 15. The above actions or inactions are a violation of Rule 58A-5.0185(5) (b), Florida Administrative Code (2003), which requires the facility to provide, for residents who receive assistance with self-administration or medication administration, a daily up-to-date, medication observation record (MOR) for each resident. The 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 of each medication prescribed, its strength, and directions for use; 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. 16. Said violation constitutes the grounds for the imposed repeat Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (c), Florida Statutes (2003), the Agency is authorized to impose a fine in the amount of five hundred dollars ($500). COUNT II RESPONDENT FAILED TO ENSURE THAT PERSONNEL RECORDS CONTAIN VERIFICATION OF FREEDOM FROM COMMUNICABLE DISEASE INCLUDING TUBERCULOSIS. Fla. Admin. Code R. 58A-5.024(2) (a) (2003) S. 400.4275(4), F.S. (2003) REPEAT CLASS III DEFICIENCY 17. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 18. A biennial survey was conducted on September 10-11, 2003. 19. On that date, based on record review the facility failed to have verification that 1 of 5 sampled employees (#4) was free from communicable disease including tuberculosis. 20. A Class III deficiency was cited against Respondent based on the findings below: Review of the record for employee #4 reveals she was hired on 7/16/03. There was no evidence of freedom from communicable disease or of TB status. 21. These observations were cited as a Class III deficiency and were tc be corrected by October 11, 2003. 22. On or about November 3, 2003, a follow-up survey was conducted at Respondent’s facility. At this time, the above- listed deficiency had been corrected. 23. On or about February 16-17, 2004, a change of ownership survey was conducted at Respondent’s facility. 24. On that date, based on personnel record review and staff interview, the Administrator failed to ensure that personnel records contained verification of freedom from communicable disease including tuberculosis within 30 days of employment for 1 of 5 (Staff #4) sampled staff. The findings include: 1. Review of Staff #4's personnel record, hired 12/2/03, Jacked documentation from a health care provider that the staff person is free from communicable disease including tuberculosis within 30 days of employment. 2. Interview with the Executive Director confirmed that Staff #4's personnel record lacked documentation of freedom from communicable disease including tuberculosis. 25. This is a violation of Rule 58A-5.024(2) (a), Florida Administrative Code (2003), which requires that personnel records contain verification of freedom from communicable disease including tuberculosis. Additionally, §400.4275(4), Florida Statutes (2003), states the department may by rule clarify terms, establish requirements for financial records, accounting procedures, personnel procedures, insurance coverage, and reporting procedures, and specify documentation as necessary to implement the requirements on this section. 26. Said violation constitutes the grounds for the imposed repeat Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (c), Florida Statutes (2003), the Agency is authorized to impose a fine in the amount of five hundred dollars ($500). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following: 1. Make factual and legal findings in favor of the Agency on Count I and Count II; 2. Impose a fine in the amount of one thousand dollars ($1,000) for the violations cited in Count I and Count II against the Respondent, pursuant to Section 400.419{1) {(c), Florida Statutes (2003); and 3. Any other general and equitable relief as deemed appropriate. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2003). 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: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, titi Dd hme “| Katrina D. Lacy, Sox AHCA - Senior Attorney Fla. Bar No. 0277400 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 (727) 552-1525 office (727) 552-1440 fax 10 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7003 1010 0002 4667 0319 to Lexis Nexis Document Solutions, Inc., Registered Agent for Brighton Gardens of Naples, 1201 Hays Street, Tallahassee, FL 32301 dated on April And oe, 2004. Katrina D. Lacy, seghire Copies furnished to: Lexis Nexis Document Solutions Registered Agent for Brighton Gardens of Naples 1201 Hays Street Tallahassee, FL 32301 (Certified U.S. Mail) Kathleen S. Tremble, Administrator Brighton Gardens of Naples 8701 Airport Pulling Road, N.E. Naples, FL 34109 (U.S. Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330G St. Petersburg, Fl 33701 PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , Which represents payment of the Administrative Fine imposed by AHCA. Facility Name AHCA No.

Docket for Case No: 04-002038