STATE OF FLORIDA - AGENCY FOR HEALTH CARE ADMINISTRATIONMAR -4 py 4:27 AGENCY FOR HEALTH CARE A OM OF ADMINISTRATION, an Atv Petitioner, AHCA No.: 2004007555 Return Receipt Requested: Vv. 7003 1680 0006 9825 7659 7003 1680 0006 9825 7666 AL INVESTORS SUNRISE LLC d/b/a 7003 1680 0006 9825 7680 SPRINGTREE RETIREMENT RESIDENCE, Respondent. iw ONG { / »> ( KY ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against AL Investors Sunrise LLC d/b/a Springtree Retirement Residence (hereinafter ‘“Springtree Retirement Residence”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $5,500.00 [$5,000.00 fine + $500.00 survey fee] 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 Broward 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 (2004) and Chapter 58A-5 Florida Administrative Code. 5. Springtree Retirement Residence operates a 246-bed assisted living facility located at 4201 Springtree Drive, Sunrise, Florida 33351. Springtree Retirement Residence is licensed as an assisted living facility under license number 7433. Springtree Retirement Residence 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. SALT ARSON RNR NEETESA ee me nn COUNT I SPRINGTREE RETIREMENT RESIDENCE FAILED TO NOTIFY PHYSICIAN OF A CHANGE IN RESIDENT CONDITION. RULE 58A-5.0182(1) (d), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0185(4) (b), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Springtree Retirement Residence was cited with one (1) Class I deficiency due to a follow-up complaint investigation conducted on July 6, 2004. 8. A re-licensure survey was conducted on July 6, 2004. Based on record review and interview, the facility failed to contact the resident’s health care provider and = other appropriate party such as the resident’s family if the resident exhibits a significant change. The finds include the following: 9. During the Resident Care Standards portion of the complaint investigation follow-up conducted on 07/06/02004, it was noted on the Medication Observation Records (MOR) for resident #1, that the resident was to get twice daily accu-check tests (one test a fasting glucose at 6:30 A.M. and another at 4:30 P.M.) The MOR further instructed that if the blood sugar was below 60 or above 300, then to call the health care provider. On 12/26/2003 and 12/27/2003, the resident’s blood sugars were documented on the MOR as follows: 12/26/2003 6:30 AM - 54 4:30 PM - 47 12/27/2004 6:30 AM - 47 10. There was no documentation to show that the health care provider was contacted for the 3 blood sugars below 60. The resident’s Wellness Record Notes were reviewed and there was no entry on 12/26/2003 and the only entry on 12/27/2003 states, “8 AM Crises Care in progress Vitas at BS.” 11. A review of the health care provider's orders documents that the accu-check tests were initiated on 04/10/2002. The Director of Nurses was interviewed and after investigation was unable to produce documentation that the health care provider was contacted and confirmed the findings. A copy of the Medication Observation Records (both sides) was obtained. 12. Based on the foregoing facts, Springtree Retirement Residence violated Rule 58A-5.0182 (1) (d), and Rule 58A- 5.0185(4) (b), Plorida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $5,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of monitoring visits. A survey fee of $500.00 has been assessed in this case. 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 Springtree Retirement Residence on Count I. 2. Assess an administrative fine of $5,000.00 against Springtree Retirement Residence on Count I for the violation cited above. 3. Assess a survey fee of $500.00 against Springtree Retirement Residence pursuant to Section 400.419(10), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. 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 A FINAL ORDER BY THE AGENCY. Tria Lawton-Russell, sq. Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6804 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 B. 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 Damon A. Thomas, Administrator, Springtree Retirement Residence, 4201 Springtree Drive, Sunrise, Florida 33351; AL Investors Sunrise LLC, P.O. Box 1411 - Attn Debbie Parsons, Salem, Oregon 97309; CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on this S!4 aay of q Ki 4 Vfl Tria Lawton- Russell, Esq.

Docket for Case No: 05-000841