STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, _ VS. AHCA No. 2005010130 MAGNOLIA PLACE, O (o- (I 3 > 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 Magnolia Place (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida . . ( Statutes (2005). NATURE OF THE ACTION eee This is an action.to impose administrative fines in the amount of $13,000 based upon six (6) uncorrected class Ill deficiencies and two (2) new class I deficiencies, pursuant to Sections 400.419(2)(a) and (c), 400.424(5) and (1), 400.4275(2) and (4), and 400.428(1)(1), Florida ’ Statutes (2005), and Rules 58A-5.0182(6)(b), 58A-5.0185()@), 58A-5.019(1) and (2)(e), 58A- 5.0191(2)(d), (3), and (11){a), 58A-5.024(1)(k), (2)(a), and (3)(), and 58A-5.025(1), Florida Administrative Code (2005). This is also an action to deny Respondent’s license renewal, pursuant to Sections 400.414(1)(a) and (1)(e)(1) and (2), Florida Statutes (2005). @ @ JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Chapter 400, Part TN, Florida Statutes, and Sections 120.569 and 120.57, Florida Statutes. 2. Venue lies in Leon County, Tallahassee, Florida, pursuant to Section 120.57, Florida Statutes, Chapter 584-5, Florida Administrative Code, and Rule 28-106.207(1), Florida Administrative Code. PARTIES 3.'The Agency is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part Tl, Florida Statutes, and Chapter 584-5, Florida Administrative Code. 4. Respondent is licensed by the Agency to operate a thirty-eight (38) bed assisted living facility located at 2767 Raymond Diehl Road, Tallahassee, Florida 32308, having been issued license number 9699. ; 5, On October 31, 2005, the Agency, with its authorized personnel, conducted a follow- up survey to a biennial licensure survey which had taken place on September 30, 2005. During the follow-up survey, the Agency determined that as of October 31, 2005, Respondent had failed to correct two (2) class I deficiencies regarding staffing and medication standards cited during the September 30, 2005 survey. Additionally, Respondent had failed to correct six (6) class II deficiencies regarding facility records, medication standards, staff records, and emergency management standards cited during the September 30, 2005 survey and failed to correct six (6) class Ill deficiencies regarding facility records, resident records, staffing standards, resident care standards, and staff records standards. Finally, the Agency cited two (2) new class I violations. : va ey COUNT I DENIAL OF LICENSE RENEWAL 400.414 Denial, revocation, or suspension of license;,imposition of administrative fine; grounds.— a Sections 400.414(1)(a), 400.414(1)(e)(1), and 400.414(1)(e)(2), Florida Statutes (2005) ‘ Section 400.441(1)(a)3, Florida Statutes (2005) ~ Rule 58A-5.019(2)(b), Florida Administrative Code (2005) Rule 58A~-5.0185(4)(a), Florida Administrative Code (2005) Rule 58A4-5.0185(6)(b)1, Florida Administrative Code (2005) Rule 58A-5.0185(6)(b)2, Florida Administrative Code (2005) Rule 584-5.026(3)(a), Florida Administrative Code (2005) Rule 58A-5.024(2)(a), Florida Administrative Code (2005) Uncorrected class I and class I deficiencies 6. Respondent's license renewal should be denied for the following reasons: a. During the follow-up survey of October 31, 2005, the Agency’s surveyors determined, via interview with the administrator, record review, and observation, that Magnolia Place did not have a licensed nurse in the facility to administer medicatidns to three (3) of the thirty-two (32) residents who required medications to be administered. Two (2) of these three (3) residents are cognitively impaired and unaware of the medications ordered. The third resident’s health assessment form indicated that his/her medications could be administered by a medical technician. Only licensed professionals may administer medications, however. Magnolia Place’s owner verbally acknowledged that no nurse was at the facility at 6 p.m. on the date of the survey. During the September 30, 2005 survey, the owner acknowledged that technicians administer medications, and the med tech interviewed affirmed that med techs do administer medications. The above practices violate Rule 58A-5. 019(2)(b), Florida Administrative Code, which provides, in part, that “[a]ll staff shall be assigned duties consistent with his/her level of education, training, preparation, and experience. Staff providing services requiring licensing or certification must be appropriately licensed or certified... : This ig an uncorrected class I deficiency from the prior September 30, 2005 survey, te during which time the Agency determined that a med technician was dispensing medications, in contravention of physician’s orders, which required medication administration by a licensed nurse. b. During the follow-up survey of October 31, 2005, the Agency determined that Magnolia Place failed to ensure that medications were administered in accordance with the physician’s orders. For example, during morning med pass on October 31, 2005, one resident (resident #30) received only one (1) of the eleven (11) medications that had been ordered. Medications that were ordered but not administered included Seroquel, a psychotropic medication used to treat acute mania associated with bipolar disorder, Lotrel, a drug used to treat hypertension, Lasix, a diuretic, and Prevacid, used to treat acid reflux. Another resident (resident #11) received only one (1) of thirteen (13) medications that had been ordered. Medications that were ordered but not administered included Atenolol , Lisinopril, K-Dur, and Klor-Con, all used to treat hypertension, and Celexa, an anti-anxiety medication. Yet another resident (resident #9) received only one (1) of two (2) medications that had been ordered. The medication that was ordered but not administered was Paxil, an antidepressant. @. Q . @ he Another resident (resident #12) received only eight (8) of the twelve (12) medications that had been ordered. Medications that were ordered but not administered included Cozaar and Imdur, both high blood pressure medications. - Finally, a resident (resident #5) requested his/her pain medication (Endocet) from the nurse at 10:45 a.m, on October 31, 2005, but as of 1:15 p.m., the resident still had not received it. | The last dose doctmented as having been administered was on October 30, 2005 at 8:00 a.m., even though the physician’s order, dated October 18, 2005, indicated that this resident was to receive Endocet every six (6) hours around the clock. The nurse on duty, whom the administrator reported was from an agency, was unable to locate any of the above missing medications. The above practices violate Rule 5 8A-5.0185(4)(a), Florida Administrative Code, which “[fJor facilities which provide medication administration, a staff member, who is provides that licensed to administer medications, must be available to administer medications in accordance with a bealth care provider’s order or prescription label.” | This is an uncorrected class I deficiency from the prior September 30, 2005 survey, during which time the Agency determined that the facility failed to have medications administered in accordance with physician’s orders. (c) During the follow-up survey of October 31, 2005, the administrator acknowledged, as she had on September 30, 2005, that the facility had never conducted any elopement prevention and response drills. Record review revealed no documentation that any elopement drills had been conducted for years 2003, 2004, and 2005 consistent with the facility’s resident elopement policies and procedures. This is in violation of Section 400.441 (1)(a)3, Florida Statutes. Pursuant to that section, Magnolia Place is required to conduct a minimum of two (2) resident elopement prevention and response drills per year, and Magnolia Place is required to document the implementation of said drills to ensure that the drills are conducted in a manner consistent with the facility’s resident elopement policies and procedures. ' . _ This constitutes two (2) uncorrected class I deficiencies from the September 30, 2005 survey. (d) During the follow-up survey of October 31, 2005, the medication nurse, who was passing out morning medications, left the medication cart unlocked and unattended in the dining t room, where four residents were seated, while she went to wash her hands. Later in the day, the medication nurse left the medication cart unattended and unlocked in the dining room for . approximately ten (10) minutes. - During the September 30, 2005 survey, a med tech had left the medication cart unattended in a sitting room for fifteen (15) minutes, whilst three (3) residents watched the television, and several other residents, family members, and children walked through the sitting room. This is in violation of Rules 58A-5.0185(6)(b) 1 and 2, Florida Administrative Code, .. which require that centrally stored medications be kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times, and that refrigerated medications must be secured by being kept in a locked container with the refrigerator by keeping the refrigerator locked or by keeping the area in which the refrigerator is located locked. The above practices constitute an uncorrected class I deficiency from the September 30, 2005 survey. e. Wy . @ (e) During the follow-up ’survey of October 31, 2005, record review of two (2) staff personnel records revealed no documentation that these two (2) staff members had ever received any training in their duties and responsibilities forimplemeniting an emergency management plan. The administrator confirmed that she could not provide any written documentation that these two (2) staff members had ever received any training in this area. This is in Violation of Rule 58A-5.026(3)(a), Florida Administrative Code, which states that “[a]ll staff must be trained in their duties and are responsible for implementing the emergency management plan.” The above practices constitute an uncorrected class If deficiency from the September 30, 2005 survey, during which the administrator confirmed that she could not provide any written documentation that any of the nineteen (19) staff members had received emergency management plan training, and record review of all staff personnel records failed to yield evidence that any staff member had ever received any training in this area. (f) During the follow-up survey of October 3 1, 2005, record review and interview with the facility’s administrator confirmed that no written documentation existed in three (3) employees’ personnel records that they were free from communicable diseases, including tuberculosis. Moreover, although freedom from tuberculosis must be documented annually, no evidence existed that these employees’ personnel records contained annual verification of freedom from tuberculosis. During the September 30, 2005 survey, record review and interview with the facility’s administrator confirmed that no written documentation existed in eleven (11) employees’ personnel records that they were free from communicable diseases, including tuberculosis. Moreover, although freedom from tuberculosis must be documented annually, no evidence eo. . @ existed that these employees’ personnel records contained annual verification of freedom from i 4 tuberculosis. The above practices violate Rule 58A-5.024(2)(a), Florida Administrative Code, which states, in pertinent part, that “[p]ersonnel records for each staff member shall _ contain.. ~verification of freedom from communicable diseases including tuberculosis.” The te , above practices also violate Rule 58A-5.019(2)(a), Florida Administrative Code, which states, in pertinent part, that “[fJreedom from tuberculosis must be documented on an annual basis.” The above violations constitute two (2) uncorrected class II deficiencies from the ‘ September 30, 2005 survey. 7. ‘Pursuant to Section 400.414(1)(a), Florida Statutes, the agency may deny an assisted living facility license for the actions of any assisted living facility or facility employee which constitute “fan intentional or negligent act seriously affecting the health, safety, or welfare of a resident of. the facility.” Moreover, pursuant to Sections 400.414(1)(e)1 and 2, Florida Statutes, the agency may deny an assisted living facility license for the citation of one (1) or more class I deficiencies or three (3) or more class JI deficiencies, respectively. As indicated, supra, Respondent was cited with two (2) uncorrected class I deficiencies and six (6) uncorrected class Il deficiencies during the October 31, 2005 follow-up survey. 8. These uncorrected class J and class I deficiencies are sufficient in and of themselves to deny Respondent’s license. Additionally, and more disturbingly, these uncorrected deficiencies place the health, safety, and welfare of the residents of Magnolia Place in jeopardy, . in contravention of Section 400.414(1)(a), Florida Statutes. 9. Two (2) class I and six (6) class Il deficiencies remained tincorrected a month after the biennial survey was conducted, despite the fact that the Agency placed Magnolia Place on notice of the multiple deficiencies at that time. The danger to current and potential residents is clearly . @ apparent. Residents are not receiving substantial portions of their prescribed medication, which creates an imminent danger to their health and well-being. Failure to administer psychotropic medications may adversely affect residents’ mental health and behavior. The failure to administer medications used to treat high blood pressure may result in residents suffering from life-threatening or deadly strokes. Additionally, when medications are administered, they are often handed out by a med tech instead of a licensed professional, which only serves to exacerbate medication errors. Residents may elope unnoticed, and remain so, as no elopement prevention and response drills have ever taken place. Residents who may be cognitively impaired may easily access prescription medications from unlocked medication carts. The ingestion of such prescription drugs is potentially lethal. Some staff members would be unaware of what to do in an emergency situation, such as a hurricane or fire, since they have never received any emergency management plan training. Other staff members may spread life-threatening tuberculosis or other communicable diseases to staff members or to the general public. WHEREFORE, the Agency intends to deny Respondent’s license renewal pursuant to the above-cited statutory authority. COUNT I FAILURE TO MAINTAIN A GRIEVANCE PROCEDURE Section 400.428(1)(1), Florida Statutes (2005) Section 400.419(2)(c), Florida Statutes (2005) Rule 58A-5.024(1)(k), Florida Administrative Code (2005) Uncorrected class II deficiency 10. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. eo Wy ‘ @ 11. During the October 31, 2005 follow-up to the September 30 2005 biennial survey, the assistant administrator was unable to produce grievance policies or procedures for the Agency’s surveyors to review. An interview with the assistant administrator at 2 p.m. on that date confirmed that the facility had no policies on how it receives and responds to residents’ _ complaints. be 1 - 12, Pursuant to Section 400.428(1)(1), Florida Statutes, every resident shall, without ' restraint, interference, coercion, discrimination, or reprisal, have the right to present to staff grievances and recommend changes to the facility’s policies, procedures and services. Each facility must establish a grievance procedure to facilitate the residents’ exercise of this right. "43. Pursuant to Rule 58A-5.024(1)(k), Florida Administrative Code, facility records include a grievance procedure for receiving and responding to resident complaints and recommendations. ' 14, .This violation, a class Ill deficiency, remained uncorrected from the September 30, : ; , 2005 survey. 15. Pursuant to Section 400.419(2)(c), Florida Statutes, the Agency shall impose an administrative fine of not less than $500 for a class III violation which is not corrected within the time specified. WHEREFORE, the Agency demands the following relief: 1. Enter factual and legal findings in favor of the Agency on Count IL. 2. Impose a fine in the amount of $500. COUNT TL FAILURE TO ENSURE THAT RESIDENTS HAD CURRENT SIGNED AND DATED CONTRACTS Section 400.424(1), Florida Statutes (2005) Section 424(5), Florida Statutes (2005) Section 400.419(2)(c), Florida Statutes (2005) 10 3 oa Rule 58A-5.024(3)(i), Florida Administrative Code (2005) Rule 58A-5.025(1), Florida Administrative Code (2005) Uncorrected Class I deficiency 16. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 17, During the October 31, 2005 follow-up survey, the Agency’s surveyors reviewed resident # 3, #15, #7, #8, #12, #13, #17, #21, #24, #27, #28, #30, #31, and #32’s resident contracts. In each instance, the resident either had no contract, or the contract was not signed or dated by a representative of the facility or by the resident, or both. 18. Interview with the facility’s administrator at 3: 30 p.m. confirmed that the above information was missing from the residents’ contracts. 19. This violates Section 400.424(1), Florida Statutes, which states, in pertinent part, “(t]he presence of each resident ina facility shall be covered by a contract, executed at the time of admission or prior thereto, between the licensee and the resident of his or her designee or legal representative... and the licensee shall keep on file in the facility all such contracts.” 20. Moreover, pursuant to Section 400.424(5), Florida Statutes, “[n]Jeither the contract nor any provision thereof relieves any licensee of any requirement or obligation imposed upon it by this part or rules adopted under this part.” 21. In accordance with Rule 58A-5.024(3)(), Florida Administrative Code, resident records shall be maintained on the premises and include “[a] copy of the resident’s contract with the facility....as described in Rule 58A-5.025, Florida Administrative Code.” 22. Pursuant to Rule 58A~-5.025(1), Florida Administrative Code, and in accordance with Section 400.424, Florida Statutes, “each resident or the residents [sic] legal representative, shall, prior to or at the time of admission, execute a contract with the facility...” 11 ; e By | ‘ @ 23. This violation, a class Ill deficiency, remained uncorrected from the September 30, 2005 survey. ' , 24. Pursuant to Section 400.419(2)(c), Florida Statutes, the Agency shail impose an administrative fine of not less than $500 for a class ILI violation which is not corrected within the time specified. ; WHEREFORE, the Agency demands the following relief 1. Enter factual and legal findings in favor of the Agency on Count II. 2. “Impose a fine in the amount of $500. COUNT IV. FAILURE TO PROVIDE IN-SERVICE TRAINING Section 400.419(2)(c), Florida Statutes (2005) Rule 58A-5.0191(2)(d), Florida Administrative Code (2005) Rule 58A-5.0191(11)(a), Florida Administrative Code (2005) Uncorrected class III deficiency '. 95°"The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. Record review of personnel files and interview with the facility administrator at 3:40 p.m. on October 31, 2005 revealed that no evidence existed that the facility had provided, within thirty (30) days of employment, three (3) hours of in-service training in resident behavior, needs, and activities of daily living to two (2) staff members (#1 and #7) who provide direct care to residents but who are not nurses. 27, Pursuant to Rule 58A-5.0191(2)(d), Florida Administrative Code, “[s]taff who provide direct care to residents, other than nurses, CNAs, or home health aides trained in accordance with Rule 59A-8.0095, F.A.C., must receive 3 hours of in-service training within 30 “12 @ ‘ @ ey days of employment that covers...1. Resident behavior and needs and 2. Providing assistance with the activities of daily living.” . | 28. Additionally, in accordance with Rule 58A-5.0191(1 1)(a), Florida Administrative | Code, “[e]xcept as otherwise noted, certificates of any training required by this rule shall be documented in the facility’s personnel files...” i . . _ 29. This violation, a class III deficiency, remained uncorrected from the September 30, 2005 survey. 30. Pursuant to Section 400.419(2)(c), Florida Statutes, the Agency shall impose an administrative fine of not less than $500 for a class II violation which is not corrected within the time specified. WHEREFORE, the Agency demands the following relief. 1. Enter factual and legal findings in favor of the Agency on Count IV. 9, Impose a fine in the amount of $500. : COUNT V' FAILURE TO IMPLEMENT A WRITTEN GRIEVANCE PROCEDURE Section 400.419(2)(c), Florida Statutes (2005) Rule 58A-5.0182(6)(b), Florida Administrative Code (2005) Uncorrected class III deficiency 31. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 32. Based on observation, interview with the assistant administrator, and record review, the Agency determined that the facility had no written grievance procedure for receiving and responding to resident complaints, and thus, the facility could not demonstrate that a written grievance procedure is implemented upon receipt of a resident’s complaint. e. .@ 33. Specifically, on October 31, 2005, the Agency requested that the assistant administrator produce a written ptievance procedure for resident complaints. The assistant administrator produced to the Agency a hard-bound book titled Grievances. Review of the book revealed one grievance and a letter for the complainant to sign when he/she files a grievance. Review of this book failed to reveal any evidence which would indicate how the facility follows ® , up and resolves resident grievances. 34. In a 1:30 p.m. interview on October 31, 2005, the assistant administrator confirmed that the facility had no written grievance procedure which made clear how the facility is to go about following up on and resolving resident grievances. The assistant administrator stated that the fability does the best it can, but she was unable to state a consistent process which the facility implements to respond to and resolve resident grievances. 35. This violates Rule 58A-5.0182(6)(b), Florida Administrative Code, which requires a facility to have a written grievance procedure for receiving and responding to resident complaints and for residents to,recommend changes to ) facility policies and procedures. The facility must be able to demonstrate that such a procedure is implemented upon receipt of a complaint. "36, This violation, a class III deficiency, remained uncorrected from the September 30, 2005 survey. 37. Pursuant to Section 400.419(2)(c), Florida Statutes, the Agency shall impose an administrative fine of not less than $500 for a class III violation which is not corrected within the time specified. WHEREFORE, the Agency demands the following relief: 1. Enter factual and legal findings in favor of the Agency on Count V. 2. Impose a fine in the amount of $500. 14 te ®@ ay COUNT. VI FAILURE TO PROVIDE HIV/AIDS TRAINING Section 400.419(2)(c), Florida Statutes (2005) Section 400.4275(2), Florida Statutes (2005) Rule 58A-5.0191(3), Florida Administrative Code (2005) Rule 58A-5.0191(11)(a), Florida Administrative Code (2005) _ Rule 58A-5.024(2)(a)1, Florida Administrative Code (2005) Uncorrected class III deficiency 38. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. ' | 39. The Agency’s record review of the personnel file for staff #7 revealed no written documentation that the facility had provided staff #7 with HIV/AIDS training within thirty (30) . days of his/her employment with the facility. 40. During an interview with the administrator at 3:40 p.m. on October 31, 2005, the administrator confirmed that she could provide no written evidence of the required training. 1 41, Pursuant to Section 400.4275(2), Florida Statutes, “(t]he administrator or owner of a facility shall maintain personnel records for each staff member which contain. ..documentation of compliance with all training requirements of this part of applicable rule...” 42. In accordance with Rule 58A-5.0191(3), Florida Administrative Code, “[nJew facility staff must obtain an initial training on HIV/AIDS within 30 days of employment, unless the new staff person previously completed the initial training and has maintained the biennial continuing education requirement. Documentation of compliance must be maintained in accordance with subsection (11) of this rule.” 43, Subsection (11)(a) of Rule 58A-5.0191, Florida Administrative Code, indicates that , “certificates of any training required by this rule shall be documented in the facility’s personnel files...” 15 e. im 44, Rule 58A-5.024(2)(a)1, Florida Administrative Code, specifies that personnel records for each staff member shall contain “[dJocumentation of compliance with all staff a training required by Rule 58A-5.0191, F.A.C.” ' 45, This violation, a class IH deficiency, remained uncorrected from the September 30, 2005'survey. 46: Pursuant to Section 400.419(2)(c), Florida Statutes, the Agency shall impose an administrative fine of not less than $500 for a class IIT violation which is not corrected within the time specified. WHEREFORE, the Agency demands the following relief: t “L Enter factual and legal findings in favor of the Agency on Count VI. 2. Impose a fine in the amount of $500. COUNT Vil ' shoe FAILURE TO PROVIDE A WRITTEN JOB DESCRIPTION Section 400.419(2)(c), Florida Statutes (2005) Section 400:4275(4), Florida Statutes (2005) Rule 58A-5.019(2)(e)1, Florida Administrative Code (2005) Rule 58A-5.024(2)(a)4, Florida Administrative Code (2005) Uncorrected class IIT deficiency 47. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48, The Agency’s personnel record review and interview with the administrator at 3:40 p.m. on October 31, 2005 revealed that no job description existed for employee #8. 49. Pursuant to Section 400.4275(4), Florida Statutes, the department may by mle clarify terms and establish requirements for personnel procedures. 16 e , @ wy 50. Rule 58A-5.019(2)(e)1, Florida Administrative Code, states that facilities with a licensed capacity of seventeen (17) or more residents shall, “[djevelop a written job description for each staff position and provide a copy of the job description to each staff member.” 51. Rule 58A-5.024(2)(a)4, Florida Administrative Code, provides that for facilities with a licensed capacity of seventeen (17) or more residents, personnel records for each staff member ° : . shall contain a copy of the job description given to each staff member pursuant to Rule 58A- 5.019, F.A.C.” 52." This violation, a class III deficiency, remained uncorrected from the September 30, 2005 survey. 53, Pursuant to Section 400.419(2)(c), Florida Statutes, the Agency shall impose an 5 Il violation which is not corrected within the administrative fine of not less than $500 for a clas time specified. ‘WHEREFORE, the Agency demands the following relief: _ 1, Enter factual and legal findings in favor of the A'gency on Count VIL 2. Impose a fine in the amount of $500. COUNT VII URE THAT PRESCRIPTION MEDICATIONS WERE REFILLED FAILURE TO ENS ND AVAILABLE IN A TIMELY MANNER AND AVAILABLE IN A TIMELY MANS Section 400.419(2)(a), Florida Statutes (2005) Rule 58A-5.0185(7)(f), Florida Administrative Code (2005) Class I deficiency 54, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 55. Through interview with a resident, resident’s family member, and staff, as well as through review of the medication observation records, the Agency determined that the facility 17 e. ‘ @ failed to ensure that prescription'medications were refilled and available for resident #4 and for resident #8 out of a total of thirty-two (32) residents. 56. An interview with resident #4 at 4:00 p.m. on October 31, 2005 revealed that he/she received his/her morning dose of Methadone (narcotic for severe pain) late, and only after complaining to the nurse that it had indeed been prescribed for him/her. Resident #4 did not . receive any of his/her other prescribed medications. Review of the medication observation record for this resident revealed that Mobic 7.5 mg. (for osteoarthritis) was ordered to be given twice a ddy.’ From the 5:00 p.m. dose on October 19, 2005, however, the meditation was circled as not having been administered. There was no explanation as to why the medication had not ‘ been given. Review of the medications available for resident #4 revealed that no Mobic was available for him/her to take. 57. Review of the current medications available and the medication observation record for resident #8 revealed that despite the fact that several medications were prescribed for this resident, interview with the med tech on duty indicated that the only medication currently available for this resident was Paxil (to treat depression). His/her prescriptions for Advair Diskus (for asthma) and Namenda (to treat Alzheimer’s) had not been available since October 25, 2005; the prescription for Prevacid (for ulcers) had not been available since October 21, 2005; the prescription for Aricept had not been available since October 23, 2005; prescriptions for Albuterol inhaler (to treat bronchospasms), Clarinex (for allergies), and saline nose spray were also not available as of October 31, 2005, nor was a prescription for Paxil available from October 6, 2005 through October 20, 2005. 58. During an interview with resident #8’s daughter on October 31, 2005, she expressed concern that resident #8 was not receiving his/her medication, and that his/her condition was deteriorating. 18 e. - @ 59. The above-cited violations are contrary to Rule S8A-5.0185(7)(), Florida Administrative Code, which states that “[t]he facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self-administration or medication administration are refilled in a timely manner.” " 60. Pursuant to Section 400.419(2)(a), Florida Statutes, “[t]he Agency shall impose an administrative firie for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation.” WHEREFORE, the Agency demands the following relief: 1. Enter factual and legal findings in favor of the Agency on Count VIII. * ) 2. Impose a fine in the amount of $5000. COUNT IX FAILURE TO SUPERVISE ADMINISTRATION OF MEDICATIONS, ASSISTANCE “WITH SELF-ADMINISTRATION OF MEDICATIONS DOCUMENTATION OF ADMINISTRATION OF MEDICATIONS, RECONCILIATION OF NARCOTICS, AND FAILURE TO ENSURE THAT MEDICATIONS WERE AVAILABLE FOR FIVE (5) an RESIDENTS ". ‘ Section 400.419(2)(a), Florida Statutes (2005) Rule 58A~5.019(1), Florida Administrative Code (2005) Class I deficiency aE hae 61. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 62. On October 31, 2005 at 2:57 p.m., the facility administrator was standing near the - medication cart while a nurse was administering medications. The nurse took a pill out of the blister pack, dropped it on the floor, picked it up, blew on it, placed it in the medication cup, and handed it to resident #4, instructing him/her to take it. The resident informed the nurse that that was not the correct pill. The administrator told the nurse to throw out the pill that had dropped 19 e. @ on the floor, and the nurse did so. The nurse then handed resident #4 another cup with a small white pill in it, which the resident said was the correct pill. As the resident attempted to take the pill, however, the pill fell on the floor, and the nurse picked it up. Resident #4 took the pill from the nurse and swallowed it. The facility administrator witnessed the above events but said nothing to the nurse and did nothing. Interview with the nurse revealed the medication was f ’ Methadone (narcotic for severe pain) 5 milligrams. 63. On October 31, 2005 at 3:55 p.m., interview and record review with employee #7 revealed that although resident #4’s narcotic control sheet for Methadone 5 milligrams noted that there were five (5) tablets left, a count by employee #7 revealed that there were in fact only four 1 4 (4) tablets remaining in resident #4’s blister pack. Employee #7 stated that the nurse had not signed out the dose given at 2:57 p.m., as noted in paragraph 62, supra. 64. Interview and record review with employee #7 at 4:10 p.m. on October '31, 2005 revealed that the narcotic counts were also incorrect for residents #7, #8, and #11. Review of resident #7’s controlled substance administration record revealed that thirteen (13) morphine sulfate tablets (narcotic for severe pain) remained, but a count by employee #7 indicated that only twelve (12) pills were left. Moreover, review of resident #7’s medication observation record and controlled substance administration record revealed conflicting information regarding the administration of morphine sulfate. 65. Employee #7 confirmed that resident #8’s narcotic contro! sheet indicated that Ativan (anti-anxiety drug) was last given on October 30, 2005 at 5 p.m., and that twenty-four (24) tablets remained. When employee #7 counted the pills, however, twenty-five (25) were left in the bottle. Record review of the medication observation record revealed that Ativan was to dministered to resident #8 at 8 a.m. on October 31, 2005. If that dose had, in fact have been a been administered, twenty-four (24) pills would have been left in the bottle. Additionally, . a although the prescription for Ativan was changed to three (3) times a day from “as needed” on October 19, 2005, review of the medication observation record on October 31, 2008 revealed that the order for Ativan three (3) times a day was not on the chart and had never been recorded on the medication observation record. Review of resident #8’s medication observation record revealed that despite the dosage change on October 19, 2005, resident #8 had been receiving Ativan on an “as needed” basis until the physician’s order change for Ativan twice a.day was recorded on October 28, 2005. 66. Interview with the hospice nurse on October 31, 2005 at 3:05 p.m. revealed that he called resident #8’s daughter because of resident #8’s “heightened state of agitation,” and he was going to call the physician to request a dose of Ativan. Resident #8’s daughter arrived at 3:10 p.m. _ She was very concerned that resident #8 was not receiving medications as ordered, and that resident #8’s condition was deteriorating. She also voiced concern that at times no nurse was available to administer medications. | », 67, Interview with resident #8’s daughter revealed that when she was visiting resident #8 on the evening of October 30, 2005, she noticed that resident #8’s oxygen tank in her room was broken, and that there was no one in the facility who could repair it. The staff person on duty did not know who to call, so resident #8’s daughter fixed the oxygen tank herself. | 68. Observation of resident #8 at 1:52 p.m. on October 31, 2005 revealed that he/she had a black and blue right eye, extending to the mid cheek. When resident #8’s daughter visited on the evening of October 30, 2005, she noted that resident #8 bad a black and blue right eye. Resident #8’s daughter stated that if resident #8 had fallen, no one had contacted her. Record review revealed no evidence of a fall or a note that resident #8 had a black and blue right eye. In an interview at 4:50 p.m. on October 31, 2005 with employee #7, employee #7 stated that resident #8’s eyes look the same, as they always have “bags.” 21 @.., .@ 69, Employee #7 confirmed that resident #11°s controlled substance administration record indicated that the last dose of Methadone administered was at 5:00 p.m. on October 30, 2005, and that there were eighteen (18) pills remaining. When employee #7 counted the pills, however, only seventeen (17) were left. Record review of the controlled substance administration record and the medication observation record revealed conflicting information. te ‘ Although the controlled substance administration record indicated that Methadone was signed out at 5:00 p.m. on October ast 26", 27", and 29"" the medication observation record for those dates and tirnes were all blank. 70. Record review for resident #12 at 4:20 p.m. on October 31, 2005 revealed that the resident required “medication supervision/administration and pain management.” The Medication observation record dated October 2005 showed.that the resident was to receive Morphine Sulfate every twelve (12) hours. The October 10" and October 12", 2005 doses were blank, however. The 8:00 a. m. dose for October 31, 2005 had initials, indicating that the medication had been given, but the narcotic control sheet for resident #12 indicated that the last mete dose of ‘Morphine Sulfate was given on October 30, 2005 at 9:00 a.m. Further, the narcotic: control sheet indicated that twenty-three (23) pills remained, but observation and interview with employee #7 confirméd‘that resident #12 only had twenty-one (21) Morphine Sulfate pills remaining. 71. Record review for resident #14 on October 31, 2005 at 4:25 p.m. revealed that the resident had dementia and required “medication administration” and “staff to administer to ensure compliance.” The medication observation record dated October 2005 indicated that resident #14 had not received any medications since October 27, 2005, including Ativan. The controlled substance administration record for resident #14 revealed that resident #14 had received Ativan three (3) times on October 29" and twice on October 30", 2005. It also , 22 S 1 @ an showed that fourteen (14) Ativan remained. In fact, observation and interview with employee #7 confirmed that resident #14 had only twelve (12) Ativan tablets remaining. 42. The facility’s administrator failed to supervise staff and agency personnel to ensure that residents received medications to treat pain and anxiety, including narcotics, as ordered by the physician. Specifically, during a general observation period at 2:25 p.m. on October 31, 2005, the surveyor, while standing near the medication cart in the dining room, observed the administrator walk to the medication cart, holding a resident by his/her arm. The administrator asked the surveyor to give a medication to the resident. ‘The surveyor informed the administrator that he/she was not an employee of the facility. The administrator then stated to the surveyor, “It is the medication lady’s first day here,” and she asked the surveyor if he/she knew where the nurse was. The administrator’s request that the surveyor administer medication to a resident demonstrates the administrator’s failure to ensure the provision of adequate care to all residents. "73, The foregoing constitute violations of Rule 5 BA-5 .019(1), Florida Administrative Code, which mandates that “[e]very facility shail be under'the supervision of an administrator who is responsible for the operation and maintenance of the facility, including the management of all staff and the provision of adequate care to all residents, as required by Part III of Chapter 400, E.S., and this rule chapter.” 74, Pursuant to Section 400.419(2)(a), Florida Statutes, “[t]he Agency shall impose an administrative fine for a cited class I violation in an amount not jess than $5,000 and not exceeding $10,000 for each violation.” WHEREFORE, the Agency dernands the following relief: 1. Enter factual and legal findings in favor of the Agency on Count Ix. 2. Impose a fine in the amount of $5000. 23 ne @.. ‘ @ CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration, requests the following relief: 1.. Make factual and legal findings in favor of the Agency on Counts 1 through IX. 2. » Deny Respondent’s renewal license. 3, Assess against Respondent administrative fines of $13,000.00 for the violations cited above. 4." Assess costs related to the investigation and prosecution of this matter, if applicable. , . 5.,.. Grant such other relief as the 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 (2005). Specific options for administrative action are set out i in the attached Election of Rights and explained in the attached Explanation of Rights. All ‘requésts 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. FAILURE TO RECEIVE OR REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Donna La Plante, Esq. Florida Bar # 966193 Agency for Health Care Administration 2727 Mahan Drive, MS #3 24 Tallahassee, Florida 32308 ' (850) 922-5873 Copies furnished to: Barbara Alford Field Office Manager Agency for Health Care Administration (Interoffice Mail) Mi CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail #7004 1160 0003 3739 1706, Return Receipt Requested, to: Angela Lynch, Administrator, Magnolia Place, 2767 Raymond Diehl Road, Tallahassee, Florida 32308, and byUS. Certified Mail #7004 1160 0003 3739 1713 to: Carolyn D. Olive, Registered Agent, 2639 Centre Pointe Blvd., Suite 201, Tallahassee, Florida 32308 on this day of December ‘ 2005. co Donna La Plante, Esq. 25 BELT IT AUT LEM Ue et PM GULMOME TM o UnUUE FA FAA NO, Sur ¢uglo/ VEL UW ZUUTT MEM ULI TH SLOT oe UnUE Th PAA WO HUT UU a. pus, OSHS Fiz. Sta (2003) STATE OF FLORIDA A AGENCY FOR HEALTH CARE ADMINISTRATION: 7c FEE 7 BD te og . S, ety “, AGENCY FOR HEALTH CARE . cor i ADMINISTRATION, Ino, TO ery ; We Go . Chk, % Petitioner, « MeO. Wipto, %n v. . . ABCANO. 2005009871 “EE? . € - MAGNOLIA PLACE (ALE), oR, f o>) ‘ o ON FOR FORMAL ADME TIVE iG ag FEE. = an om Se MAGNOLIA PLACE, by and through its andersigned counsel, Bles its PETITIONFOR . ri FORMAL ADMINISTRATIVE HEARING pursnant to Chapter 120.57(1), Fla. Stat. (2003) and. “ says: 1. This is & Petition for Formal Administrafive Heating pursoont to." Section . SEATEMENT OF PARTIES 2 Magnolia Place is an ascister living facility, licensed by the Stute of Flodda, and ss located at 2767 Raymond Dichl Road, Tallahassee, Florida 32308, 3. ‘Magnolia Plnca’s legal representative is the Law Offices of Goldsmith, Grout & Lewis, P-A., with atelephone contact number of (407) 740-0144. , 4. ‘The aesicy affected is the Agency for Health Core Administration Agency”), swhose eddress is 2727 Mahan Drive, Tallahassee, Florida 32308. 5. The office directly responsible for the action, set ont in a letter dated ‘November 17,2005 (attached as Pxhibit A) sod in this Petition, is the Assisted Living Unit located at 2727 Mahan Drive, Tallahassee, Florida 32308. EXHIBIT. & a POUT es UOT Ih Us.et PM GULYONMIGn & GRUUT FA FAA NO, GUS fSUalol Poll DECAUT-AIDS-WED B22 PR GULMOMI 1H & GEUUL PA HAL NO, AUTTQUTTOE Fr. uus 6. Magnolia Place received notice of the Agency's proposed intent to deny Magnolia Places repewal application. WL. STATEMENT OF SUBSTANTIAL INTEREST i) [ | 7, Mapua Place bs sinning ole ths Pettis beats subst se : { | IL SUATEMENT OF NOTICE | { have been direct affcted by the Agency action tn deny Magnolia Place’ 's renewal remy TV. STATEMENT OF DISPUTED ISSUES OF MATERIAL FACT. re 3. This Petition for Foumal Adminismetive Hearing arises out of a decision by ABCA tw deny Magnolia Place's renewal application as a result of alleged new class I and uncorrected Class J, IZ, and Il deficiencies resulting fom surveys conducted by the Agency on September 30 md October 31, 2005. ABCA contends fhnt Magnolia Place: . A. Failed to meet Heensure standarde in atcondance with section 400.414(1}(€)1, 2 and 3, Fiz. Stat. (2003). ; oo THE AAR assets ero the Ouasber 2; 2005-fallow-up tothe biemial-srve yo poo concluded on September 30, 2005, that there were 2 new class ¥, 2 uncorrected class I definiencies, 6 uncorrected class II deficiencies and 6 uncorrected class Il deficiencies. ¥v st OFF, IN DIFICATION OF BY is] Ss Ww. As to the alleged deficient pmctices, the facility staff at all times matezial hereto provided appropriate care to the alleged affected residents. 11. Magnolia Place responds to the intent wo deny as follows: | | A. Magnolia Place asserts that it did and docs meet liceasure standards. Iris the pasition of Magnolia Place that either the deficienries cited during the survey that concluded PELT EI UUITINY US 22 PM GULUOML EA & GROUT PA PAa Wo, 4U//40010/ rule UBG-UT=20US-WEU) WES) eM GULUBMLIM & GXUUL TA PAA AO, qUFFRUDIOS. hue) on September 30, 2005, were either pot deficiencies or were comected prior to the follow up | survey conducted on October 31, 2005. B. As to the class T deficiencies, Magnolia Place will prove, among ofber things, that it complied with the stuffing, requizemsnis and medication standards during both surveys. On the resurvey, the facility was cited for A 500, which requires that the facility be under fhe supervisions of sa administrator responsible for the operation and maintenance of the . | fusilty, including managing steff, and providing adequate care to ail residents. There was at sl. : times an administrator employed by the facility who supervised fhe facility. There is no | evidence that she did not manage ull staff There is no evidence that any failure on the part of 1 the administrator resulted in inadequate care to the residents. The Agency is holding this | administrator to a higher standard. than xequired by law. There is 10 evidence that acy action or innetion om the part of the administrator rose to fhe level of a class T deficiency. Yn fact, facts will ! be established at the hearing which will prove the opposite. ‘The facility was also cited for A 515 [tetris seamsistent-vith-cdneation; taining and-eaqpesiemer ys sone In fact, the residents cited were receiving care approptinte to their needs diom a person qualified, as required under A 515. Magnolia Place was also cifed under A 612 for foiling to administer meds in accordance with physician's orders. Becouse the nurse was an agency nurse and the facility had two med carts (it was in the process of changing pharmacies) there was some confusion, during the 11:00 med poss. Hai the surveyors given the modication nurse an. | oppormmity to complete the medpass and disenss her concerns with the administrator the issue of | “missing” medications would have been resolved and the proper medications administered fimely. The facility was also cited for A630 regarding medication standards, alleging fhat | medications were not available. The facility had done evoryihing required by law to assure that | residents’ medications were available as prescribed. , 3 PEST EIT EUUIT IL US ee PM GULUOMT EM & GRUUL FA PAA NG, 4Uff4Uaiof tr, did DEC-H/-2UU5-WED B20) PR GULEOMI IM & UKUUL TA FAA WO, SULTRUTLOL uy wus 1 } | Cc. As to the allegedly uncorrected class IT deficiencies, Magaolia Place will | show that A 222 and 223 rested in pert from papers not being pmpecly Bled and, in those instances, there wos no potential for bara to the resideaty, In onc case the assistant administrator "njeunderstood the surveyors’ request. Magnolia Plae did bave the required drills. As to A 618 craft nurses were advised that the medication cart is tobe kept locked at al Himes. As to 1101, 1102 all employes were propesly tated, Ar to 1117 employee #8 di have a job description . which hail been stolen from her fle. od. As to the alleged meorrected class IIT deficiencies: A 309 requires signed contracts. Two of those cited were to be ‘signed promptly, afer residents completed the approprinte backup paperwork, "Che others related to the facility not signing the contract. Most, j€ not all, of these contracts were signed. Even as to those which were not, the residents were receiving the care and their needs were being met. The failure af the staff to sign the contact not oly did not harm the residents tut had no potential to do so. ‘The contract waa the facility 625 aoe fom docoment mining Som pease es. ‘The files had been sabotaged before . the first survey and the facility could not reproduce same items. Therefore, if the funility had i replaced those items it could, it should be deemed in complisnee, A 635 is based on ofher tags | already discussed herein. A719 involves the facility's grievance system which was in-place. As | to A. L104, the facility was in'complinnce with this requirement | E. ‘Magnolia Place denies each and every allegation piven rise to the denial of | its renewal application. VL STATEMENT OF STATUTORY SUPPORT, | D Magunlia Place contends thst it is not subject to the denial of its renewal ; application. LTeo7UUac Eu Garde PM GULUOMI TA & GRUUT PAR FAA NGO. U7 /4U3 TDF roUie DEC-W7-2UUS-WED UZ011 YH GULUSMITH & GRUUL PA FAR NO. 4U728U9100 © : 5. WUD: 2B. A class I deficiency ix a deficiency that the ageacy determines presents sitcation in which immediate corrective action is necessary because the facility's noncompliance Js caused, or is likely to canse, serions injury, bom, impairment, or death to a resident receiving care in a. facility. The condition or practice constitnting « class I violation shall be abated or eliminated immediately, woless a fixed periad of tiny, as determined by the agency, is required for correction, Aclans[ deBciency is subject to a civil penalty of $10, 000 for an isolated deficiency, $12,500 for a puttamed deficiency, and $15,000 for a widespread deficiency. The fine amount ghall be doubled for each deficiency if the facility was previously cited for one or more class T or class TI deficiencies during the last annual inspection or any inspecting or complaint investigation since the last amaml inspection. A fii monst be levied notwithmanding the conetion of the deficiency. , 14. Section 400.419(1)(b), Fla Stat, (2003) defines a Class IL violation as ant that directly threatens the physical or emotional healt, safety or secmity of the facility residents. indirectly or potentially threatens the physical or emotinn health, saftiy, or seourity of facility residents. . 16, Section 400.414(1)(e)2 and 3, Pia. Stat. (2003) provides'a basis upon which the Agency may deny an application forslleged deficiencies. Vi. STA OF RELIEF 17. The facts presented in the hearing will demonstdte that Magaolia Place is not |___ cnr eer nr arnee t— | mibject to the denial of itz renewal applicsition. The posttion of the Agency is contrary to the facts and/or the Law. WHEREFORE, Magnolia Place requests tbe following rehe£ BENS UUITT EU Us.ee PM GULUOMitM & GROUT FA PAA NO, 4U 7 /4uaL07 PUL DEC-US-2UUS-WED UZ) PR GULUOMITH & GROUT FA Fad 80, AUS 74UN OF . Tus A. Tht this matier be forwardod to the Division of Administrative Heovings | pursuant tp Section. 120.57(1), Fla. Stat (2003); | B. That. a Recommended Order and a Final Order be entesed finding that Magnolia Place is not subject to the denial of its recewal application; and , | C. Tantattomeys’ foes and cotts be awarded to Magnolia Place. | RESPECTFULLY SUBMITIED this_/ 7" day of December, 2005. HEREBY CERTIFY that the foregoing has been Tumnished ly facsimile at (850) 5214 | . CERTIFICATE, OR SERVICE 0158 to the Agenoy Clerk, Agency far Beslth Core Administration, on this qe day of December, 2005. GOLDSMITH, GROUT & LEWIS, PA | 2180 Park Avenue North, Suite 100 | ‘Winter Park, Floxide 32789 , ‘Telephone: (407) 740-0144 i Facsimile: (407) 740-5167 | Attamey for Respondent ] SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY A. Signatura ay 4 ‘oO Agent x [he i C Adciressee B. Rgqeived by (, ted | a) AE Rod thee. ™ Complete items 7, 2, and 3. Also complete item 4 if Restricted Delivery is desired, ™ 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 maiipiece, or on the front If space permits, G. Date of Delivery [2-12 Qs D, Is delivery acdress from item 1? (7 Yes If YES, enter delivery address below: No 1. Articta Addressed to: ; JlUPY ST dbo Lgnolia Fl ace nd LP) Lay a Zz fe 7 faym and Loh Ii 9 3. Service Type -EFSeriified Mail C1 Express Mall ellahas ste, f@. 3BZIO8 O Registered O Return Fecelpt for Merchandise O Inswed Mat = C.0.D. | 4. Restricted Delivery? (Extra Fee) Ol ves 7004 L260 0003 3734 A?7Ok. .: Domestic Return Receipt 102595-02-M-1035 2. Article Number (Transfer fromiservice label! | i

Docket for Case No: 06-001133