ys ep STATE OF FLORIDA PELE AGENCY FOR HEALTH CARE ADMINISTRATION ” O6 SEP 13 PH 4: 95 STATE OF FLORIDA, DIVISION AGENCY FOR HEALTH CARE ADHINISTRATIVE ADMINISTRATION, HEARINGS Petitioner, AHCA NO: 2006006151 v. CERTIFIED MAIL NO: 70041160000337391 935 KIVA OF PALATKA, Respondent. ; () L . 4 UY 7 4 ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through undersigned counsel, and Files this Administrative Complaint against Kiva of Palatka ‘(hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose upon Respondent, in accordance with Rules 58A-5.0181(2) (a)1-8 and Rule 58A- 5.0185(6) (a), Florida Administrative Code, and Section 400.419(2)({c), Florida Statutes (2005), an administrative fine in the amount of fifteen hundred dollars ($1500). The imposition of this fine is based on two (2) uncorrected class III deficiencies. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections “490.569 and 120.57, Florida Statutes (2006), and Chapter 28-106, Florida Administrative Code. 3. Venue lies in Putnam County, Division of Administrative Hearings, pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The State of Florida, Agency for Health Care Administration is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 429,71 Part I, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code. . 5. Respondent is an assisted living facility located at 201 Zeagler Drive, Palatka, Florida 32177. Respondent was, at all times material hereto, a licensed facility under Chapter 429, Part I, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code. COUNT TI RESPONDENT FAILED TO ENSURE THAT THE MEDICAL EXAMINATION REPORT FOR SIX (6) OF SEVEN (7) SAMPLED RESIDENTS CONTAINED THE REQUISITE INFORMATION RULES 58A-5.0181(2) (a)1-8, FLORIDA ADMINISTRATIVE CODE SECTION 400.419(2)(¢), FLORIDA STATUTES (2005) UNCORRECTED CLASS III DEFICIENCY 'Pormerly Chapter 400, Part III (2005). 2 6. AHCA re-alleges and incorporates paragraphs (1) through (5)-.as if fully set forth herein. 7. The facts are that on April 14, 2006, an Agency surveyor conducted a follow-up survey to a complaint investigation which took place on March 7, 2006. 8. Based on record review and staff interview, the Agency surveyor determined that Respondent failed to have completed Health Assessment Forms for three (3) of five (5) residents, in violation of Rules 58A-5.0181(2)(a)1-8, Florida Administrative Code, a class III deficiency. 9. Pursuant to Rule 58A-5.0181(2) (a)1, Florida Administrative Code, a resident’s medical examination report must contain the physical and mental status of the resident, including the identification of any health-related problems and functional limitations. In accordance with Rule 58A- 5.0181(2) (a)2, Florida Administrative Code, the resident’s medical examination report must contain an evaluation of whether the resident will require supervision or assistance with activities of daily living. Pursuant to Rule S8A- 5.0181(2) (a)3,Florida Administrative Code, the resident's medical examination report shall contain any nursing or therapy services required by the individual. Rule 58A-5.0181(2) (a)4, Florida Administrative Code, states that the resident’s medical examination report must contain any special diet required by the ba resident. Pursuant to Rule 58A-5.0181(2) (a)5, Florida Administrative Code, the resident’s medical examination report must contain a list of current medications prescribed, and whether the resident will require any assistance with the administration of medication. Rule 58A-5.0181(2) (a)6, Florida Administrative Code, mandates that the resident’s medical examination report contain whether the resident has signs or symptoms of a communicable disease which is likely to be transmitted to other residents or staff. In accordance with Rule 58A-5.0181(2) (a)7, Florida Administrative Code, a resident's medical examination report shall contain a statement that, in the opinion of the examining physician or ARNP, on the date the examination is conducted, the resident's needs can be met in the assisted living facility. Finally, Rule 58A- 5.0181(2)(a)8, Florida Administrative Code, states that the medical examination report must contain the date of the examination and the name, signature, address, phone number, and license number of the examining physician or ARNP . 10. In the instant case, the Agency surveyor, through record review, determined that three (3) of five (5) residents did not have completed Health Assessment Forms (residents #1, #2, and #5). 11. Specifically, two (2) residents’ reports (residents #1 and #2) did not contain a statement that the residents’ needs could be met in the assisted living facility. 12. For resident #1, the nursing/treatment/therapy service requirements, special diet instructions, date of examination, name of examiner, Florida License number, address and phone number, and the physician’s or ARNP’s signature were also not documented. 13. For resident #2, mental health limitations, treatment/therapies, and the date of the examination were also missing. 14. Finally, for resident #5, the report did not contain the resident's known allergies, height, weight, medical history and diagnoses, physical or sensory limitations, cognitive or behavioral status, or nursing/treatment/therapy service requirements. Special precautions and supervision assistance needed was also absent from this resident’s record. 15. The Agency provided Respondent with a correction date of May 14, 2006. 16. On May 30, 2006, Agency surveyors conducted an unannounced follow-up to the April 14, 2006 follow-up to a complaint investigation, in conjunction with Respondent's biennial survey. in 17. Based on record review and interview with the facility, Agency surveyors determined that the medical examination reports for six (6) of seven (7) sampled reports did not contain the information required by Rules 58A-5.0181(2) (a)1- 8, Florida Administrative Code. 18. Specifically, residents #3, #4, and #10's records did not contain a statement that the residents’ needs could be met in an assisted living facility. 19. Residents #3, #4, #9, and #11’s’s records did not contain documentation of the residents’ height or weight. Resident #4's record further did not contain documentation of any known allergies, and resident #11's record did not contain a birth date. 20. Resident #2’s record did not contain an examining physician’s statement regarding whether the resident had a diagnosis of mental retardation or seizure disorder, nor was an assessment of the resident’s mental health limitations contained in the record. Treatment/therapies were also not documented, and it was documented that resident #2 could self-administer medications. 21. Resident #9's record did not contain the date of the examination, the name of the examiner, the medical license number, or the address and phone number of the medical examiner. 22. Resident #10's record did not contain the examiner's signature, the date the examination was conducted, the name of the examiner, the medical license number, or the address and phone number of the medical examiner. 23. The above constitute violations of Rules 58A- 5.0181(2) (a)1l- 8, Florida Administrative Code. 24. The above constitute uncorrected class III deficiencies for which a fine of $500 is statutorily authorized pursuant to Section. 400.419(2) (c), Florida Statutes (2005). COUNT II RESPONDENT FAILED TO ENSURE THAT RESIDENTS WHO STORED THEIR OWN MEDICATIONS (PRESCRIPTION OR OVER-THE-COUNTER) IN THEIR ROOMY KEPT THE MEDICATION LOCKED OR IN A SECURE PLACE OUT OF SIGHT OF OTHER RESIDENTS RULE 58A-5.0185(6) (a), FLORIDA ADMINISTRATIVE CODE SECTION 400.419 (2)(c), FLORIDA STATUTES (2005) UNCORRECTED CLASS III DEFICIENCY 25. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. Based on random observations and interview during the April 14, 2006 follow-up survey to the complaint investigation of March 7, 2006, the Agency surveyor determined that Respondent failed to ensure that residents who stored their own medications in their rooms had their medication locked in a secure area out of other residents’ sight. 27. This contravenes Rule 58A-5.185(6) (a), Florida Administrative Code, which states that a resident's medication which is kept in a resident’s room must be kept locked when the resident is absent unless the medication is in a secure place within the room or in some other secure place which is out of sight of other residents. 28. Specifically, multiple medications were left unsecured in resident #1'’s room, and interview with the administrator revealed that she was unaware of this. 29. Unsecured medications were also discovered in room #20, which the resident stated was not locked. 30. The Agency provided Respondent with a correction date of May 14, 2006. 31. As stated above, on May 30, 2006, Agency surveyors conducted an unannounced follow-up to the April 14, 2006 follow- up to a complaint investigation, in conjunction with Respondent's biennial survey. 32. On that date, Agency surveyors discovered prescription eye drops and over-the-counter Chloraseptic spray unsecured ‘in room #20. Additionally, the surveyors noted adjoining bathrooms which could allow access to the unsecured medications. 33. During an interview with the administrator on that same date, she stated that she was unaware of the unsecured medications in room #20. ° e 34. The above constitute violations of Rule 5BA- 5.0185(6) (a), Florida Administrative Code. 35. The above constitute uncorrected class III deficiencies for which a fine of $1000 is statutorily authorized pursuant to Section 400.419(2)(c), Florida Statutes (2005). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration respectfully requests that the Court order the following relief against Respondent: (A) Make factual and legal findings in favor of the Agency on Counts I and IT; (B) Recommend an administrative fine against Respondent in the amount of $1500. (C) Assess attorney’s fees and costs; and (D) All other general and equitable relief allowed by law. Respondent is notified that it has a vight 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 form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. 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. Respectfully submitted, N a6vee Donna La Pl&nte, Esq. Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail, Return Receipt No. 70041160000337391935, to Registered Agent/ Manager, Thomas D. Scarbor, h, 201 Zeagler Drive, Palatka, Florida 32177 on this the“ racecee of July 2006. Donns LaPlante, Esquire Copies furnished to: Kriste Mennella Field Office Manager Division of Health Quality Assurance (Interoffice Mail) Alberta Granger Assisted Living Unit Manager Bureau of Long Term Care Services (Interoffice Mail) SENDER: COMPLETE THIS SECTION Complete Items 1, 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 mailpiece, or on the front ff space permits. 20/ Zeagler Ly Bla tha, Fe BAV7? COMPLETE THIS SECTION ON DELIVERY 1 Agent (1 Addressee G. Date of Dellvery t——| Lf TIF LN . ice Type ‘artified Malt 1 Express Mail |. Is delivery address different from liam 1? (1 Yes If YES, enter delivery address betow: O No © Registered O Return Receipt ir Merchandise O Insured Mall = 6.0.D. ki , of Fz? la tk 4, Restricted Delivery? (Extra Fae) Ci Yes 2. Article Number 37439 W445 Cransierrom senicslitey | POON LEED OO03 S700. PS Form 3811, August 2001 Domestic Aeturn Recelpt 102585-02-M-1035 i

Docket for Case No: 06-003473