STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004008452 Return Receipt Requested: v. 7003 1680 0006 9825 7543 7003 1680 0006 9825 7550 ALTERRA HEALTH CARE CORPORATION 7003 1680 0006 9825 7567 d/b/a ALTERRA STERLING HOUSE OF TEQUESTA, . Respondent. / a Uf : YC. ‘6 o- ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Alterra Health Care Corporation d/b/a Alterra Sterling House of Tequesta (hereinafter “Alterra Sterling House of Tequesta”), pursuant to Chapter 400, Part IIT, and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This igs an action to impose an administrative fine of $500.00 pursuant to Sections 400.414 and 400.419, Florida Statutes 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 (2003) and Chapter 58A-5 Florida Administrative Code. 5. Alterra Sterling House of Tequesta operates a 55~bed assisted living facility located at 205 Village Blvd., Tequesta, Florida 33469. Alterra Sterling House of Tequesta is licensed as an assisted living facility under license number 8833. Alterra Sterling House of Tequesta was at all 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 ALTERRA STERLING HOUSE OF TEQUESTA FAILED TO ENSURE THAT AN UP- TO-DATE MEDICATION OBSERVATION RECORD (MOR) WAS MAINTAINED. RULE 58A-5.0185(5) (b), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Alterra Sterling House of Tequesta was cited with one (1) Class III deficiency due to a re-licensure survey that was conducted on July 26, 2004. 8. A re-licensure survey was conducted on July 26, 2004. Based on observation, record review, and interview the surveyor determined that the facility did not ensure that an up-to-date medication record is maintained. The findings include the following: 9. Three of three resident records sampled did not have accurate and up-to-date medication assistance records 10. The medication record of resident # 1 was noted to be missing any indication as the whether the resident received his/her morning medications on 7/13/04. The medications to be received were- Quinine, Aricept, Detrol, Zoloft, and Celebrex. 11. The medication record of resident # 2 was missing any notations as to whether the Hydriocodone prescribed was taken on the morning of 3/24/04 and the night of 3/26/04. 12. The medication record of resident #3 did not indicate whether the resident took the medication prescribed for the morning and afternoon of 4/13/04. The medications to be administered were Seroquel, Exelon, K-tab and Metoprolol. 13. The medication observation records for the 27 residents who received their morning medication on the date of the survey were incomplete. No entries were made for any of these residents by the LPN who assisted them. 14. During an interview with the LPN who administered the medication in the morning stated that she does not record the medications for anyone until all the medications are administered since this better enables her to get them all done. 15. The mandated correction date was designated as August 25, 2004. 16. A revisit survey was conducted on August 26, 2004. Based on record review and interview the surveyor determined that the facility did not ensure that an up-to-date medication observation record (MOR) was maintained. The findings include the following: 17. Eight of 26 resident records reviewed were found to be incomplete and inaccurate. 18. Resident # 1's medication record was missing an indication as to whether’ the resident received his/her medications on 8/25/04. The medication to be administered was Stalevo at 8 PM. 19. The medication record for resident #2 reflected that the resident received Seroquel at 4 PM on 8/26/04. This was already recorded for 8/26/04 although it was not yet 4 P.M., but only the morning of 8/26/04. 20. The medication record of resident #3 was missing an indication as to whether the resident received his/her medications on 8/25/04. The medication to be administered was Ensure at 8 P.M. 21. Resident #4’s medication record was missing any indication as to whether the resident received his/her medications on 8/25/04. The medication to be administered was Oystercal at 8 PM. 22. The medication record of resident #5 was missing an indication as to whether the resident received his/her medications on 8/25/04. The medications to be administered were Effexor XL and Namenda at 8 PM. 23. Resident #6'S medication record was missing an indication as to whether the resident had his/her TED Hose removed on 8/25/04 at 8 PM. 24. The medication record of resident #7 was missing a notation as to whether the resident received his/her medications on 8/25/04. The medications to be administered were Restasis eyedrops at 4 PM and Benefiber. 25. The medication record of resident #8 was missing an indication as to whether the resident received his/her medications on 8/25/04. The medication to be administered was Cardizem at 4 PM. 26. The facility nurse was present and confirmed these observations. This is an uncorrected deficiency from the survey of 7/26/04. 27. Based on the foregoing facts, Alterra Sterling House of Tequesta violated Rule 58A-5.0185(5) (b), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. 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 Alterra Sterling House of Tequesta on Count I. 2. Assess an administrative fine of $500.00 against Alterra Sterling House of Tequesta on Count I for the violation cited above. 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 (2003). 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 DER BY THE AGENCY. Lf. MY Tria Lawton-Russell, Esq. Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 ~ Miami, Florida 33166 305-470-6801 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 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) 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 Carolyn Hartwig, Administrator, Alterra Sterling House of Tequesta, 205 Village Blvd., Tequesta, Florida 33469; Alterra Healthcare Corporation, 10000 Innovation Drive, Tax Dept. Milwaukee, Wisconsin, 53226; CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on this TE Lush Tria Lawton-Russell, Esq

Docket for Case No: 04-004082