STATE OF FLORIDA OES AGENCY FOR HEALTH CARE ADMINISTRATION 30 p H STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2005010805 PINELLAS COUNTY HOUSING AUTHORITY, d/b/a MAGNOLIA GARDENS, a (5 ~ l | 30 Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against PINELLAS COUNTY HOUSING AUTHORITY, d/b/a MAGNOLIA GARDENS (hereinafter “Respondent”), pursuant to §§ 120.569 and 120.57, Fla. Stat. (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $1,500.00, based upon Respondent being cited for one State Class II and one repeated State Class III deficiency pursuant to §§ 400.419(2)(b) and (c), Fla. Stat. (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part III, Fla. Stat., and Chapter 58A-5 Fla. Admin. Code, respectively. 4. Respondent operates a 110-bed assisted living facility located at 3800 62" Avenue, North, Pinellas Park, Florida 33781, and is licensed as an assisted living facility, under license number 10314. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I ) 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to Fla. Admin. Code R. 58A-5.019(3)(a), all staff, hired on or after October 1, 1998, to provide personal services to residents must be screened in accordance with § 400.4174, Fla. Stat. (2005) and meet the screening standards of § 435.03, Fla. Stat. (2005). 8. On or about 12/01/05, the Agency conducted a complaint investigation (CCR# 2005008530) of Respondent's facility. 9. Based on record review and interview, the facility failed to ensure two employees sampled (Employee # 1 and Employee # 3) were in compliance with level 1 background screening as indicated by a lack of documentation in both employee records. 10. Review of Employee # 1’s record revealed a hire date of 07/30/03. 11. The record also revealed that level 1 background screening was performed by the facility and documented charges that would exclude the employee from employment under Chapter 435 Florida Statutes. 12. The facility issued a Notice of Separation on 09/24/03 to the employee for reasons of Ww failure to pass physical/drug screen/background check. 13. Further review of the employee file, included a letter from the Florida Department of Law Enforcement (FDLE) revealed that the FDLE “were unable to determine whether the employee has a criminal history, due to non submittal of fingerprints requested by the department.” 14. Contained within the employee’s file were two sets of fingerprints; one of the employee, and another of the employee's family member. 15. An interview on 12/01/05 with the Administrator, Resident Care Coordinator and facility CEO, revealed that these fingerprints were to have been sent back to the FDLE for comparison and that no documentation existed that this had been done at the time of survey. 16. The Administrator stated that the employee was still employed at the facility and last worked one day prior to the survey; 11/30/05. 17, Review of Employee # 3’s employee record revealed a hire date of July, 2004. 18. The record revealed that a level 1 background screening was performed by the facility for Employee # 3 and revealed charges that would exclude the employee from employment under Chapter 435 Fla. Stat. 19. The file did not include clearance of charges on the employee’s record by the screening unit. 20. The employee was working as a certified nursing assistant (C.N.A) at the time of the survey. 21. On 12/02/05, the Agency's Background Screening Unit was contacted and revealed that the facility was to provide additional documentation to the unit for Employee # 1 and Employee # 3, requested in 2003 and 2004, respectively, and these documents had not been provided. 22. Therefore, neither employee was provided level 1 clearance from the unit and should not be presently working in patient care areas. 23. The Agency determined that this deficient practice was related to the personal care of the resident, which the Agency determined directly threatened the physical or emotional health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 24. The Agency provided the Respondent with a mandatory correction date of 12/02/05. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b) Fla. Stat., (2005). COUNT II 25. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. Pursuant to Fla, Admin. Code R. 58A-5.0185(7)(a), no prescription drug shall be kept by the facility unless it is properly labeled and dispensed in accordance with Chapters 465 and 499, Florida Statutes. 27. On or about 08/16/05, the Agency conducted complaint investigations (CCR# 2005006892 and 2005007026) of Respondent's facility, 28. Based on observation, record review and interview, the facility failed to label prescription medications for 1 of 3 residents. 29. During medication reconciliation on 08/16/05, Bismuth Caplets 262 mg. (40 tablet bottle) medication was found unlabeled for Resident #7. . 30. The caregiver confirmed the above and stated the resident has an order for the medication and receives assistance with medications. 31. Record review of the health assessment Form1823, dated 03/08/05, revealed the resident receives assistance with medications. 32. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class III deficiency. 33. The Agency provided Respondent with a mandatory correction date of 09/16/05. 34, The deficient practice was corrected by 09/27/05. 35. On or about 12/01/05, the Agency conducted a complaint investigation (CCR# . 2005008530) of Respondent's facility. 36. Based on observation and interview, the facility failed to ensure adherence to expiration date labeling guidelines involving three of six vials observed. 37. Observation of the facility’s medication refrigerator on 12/01/05, revealed the following items without dates of initial opening annotated: Two opened vials of Novolog 70/30 with fill dates of 10/17/05 One opened vial of Novolin 70/30 with a fill date of 10/29/05 38. Interview with the medication technician at the same time of observation confirmed that these items should have been dated when initially opened in order to adhere to the expiration guidelines of labeling. 39. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the resident that indirectly or potentially threatened the heaith, safety, or security of the residents and cited Respondent for a repeated State Class II deficiency. 40. The Agency provided Respondent with a mandatory correction date of 01/01/06. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2005). Respectfully submitted this? Glaay of February 2006. Urabe) erald L. Pickett, Esquire Fla. Bar. No. 559334 Agency for Health Care Administration 525 Mirror Lake Drive, 330K. St. Petersburg, Florida 33701 (727) 552-1526 (office) (727) 552-1440 (fax) 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida 32308. Telephone (850) 922-5873. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY, that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7005 1160 0002 2254 7774 on February a 2_, 2006 to: Darlene J. Kalada, Director, Pinellas County, Housing Finance Authority, 600 Cleveland Street, Suite 800, Clearwater, Florida 33755, and by U.S. Mail to: Lucia Pena, Administyator, Magnolia Gardens, 3800 62" Avenue, North, Pinellas Park, Florjda 337 Cex) Gerald L. Pickett, Esquire Ne Copies furnished to: Darlene J. Kalada Director Pinellas County, Housing Finance Authority 600 Cleveland Street, Suite 800 Clearwater, Florida 33755 (U.S. Certified Mail) Lucia Pena Administrator Magnolia Gardens 3800 62™ Avenue, North Pinellas Park, Florida 33781 (U.S. Mail) Gerald L. Pickett, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, 330K. St. Petersburg, Florida 33701 (Interoffice Mail) 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. Magnolia Gardens 2005010805 Facility Name AHCA Case No. ‘COMPLETE THIS SEGTION ON DELIVERY ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is destred, @ Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mallplece, or on the front If spacé permits. 1. Articla Addressed to: Darlene J. Kad ada. D. Is delivery address different from Item 1? Yes {f YES, enter delivery address below: © No Maano liar Gawdlend ponee Kusthor ) 3,-Servitetypea Ci Certified Mall) C1 Express Zoo] Raasteed . ; ; O Insured Mail C1 COD. 4 ( lea ater Elon, ola. < a1 acy 4, Restrictad Nalluarw? +g Fee) Cl Yes gage 2254 7774 ——————_ ; Cert fo soerarey Oe SE OE 200501 0805" 1 PS Form 3811, February 2004 Domestic Retum Receipt 102595-02-M-1546

Docket for Case No: 06-001130