OF Han, Ome STATE OF FLORIDA ? Map l6 AGENCY FOR HEALTH CARE ADMINISTRATION an a Vv, bag Ais ypslont STATE OF FLORIDA, AGENCY FOR HEALTH Hp OTR A CARE ADMINISTRATION, ORME Petitioner, AHCA No.: 2006009945 . Return Receipt Requested: Vv. : 7002 2410 0001 4235 3822 7002 2410 0001 4235 3839 N7-196> GOLDEN DIVERSIFIED SERVICES, INC. d/b/a GOLDEN SANDS RETIREMENT HOME, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA” ) , by and through the undersigned counsel, and files this administrative complaint against Golden Diversified Services, Inc. d/b/a Golden Sands Retirement Home (hereinafter “Golden Sands Retirement Home”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2006), and alleges: NATURE OF THE ACTION 1. This is an action to impose a revocation of the assisted living facility license pursuant to Sections 429.14(1) (e) and 429.19, Florida Statutes (2006), for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and Chapter 28-106, Florida Administrative Code (2006). 3. Venue lies in Broward County pursuant to Section 120.57, Florida Statutes (2006), and Rule 28-106.207, Florida Administrative Code (2006). 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 429, Part I, Florida Statutes (2006), and Chapter 58A-5 Florida Administrative Code (2006). 5. Golden Sands Retirement Home operates a 14-bed assisted living facility located at 809 N. BE. 2ot Avenue, Fort ° lauderdale, Florida 33304. Golden Sands Retirement Home is licensed as an assisted living facility under license number 5433. Golden Sands Retirement Home 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 GOLDEN SANDS RETIREMENT HOME FAILED TO MAINTAIN AN UP-TO-DATE AND ACCURATE MEDICATION OBSERVATION RECORD (MOR) . 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. Golden Sands Retirement Home was cited with three (3) Class I deficiencies, one (1) Class ITI deficiency, and two (2) Class III deficiencies due to complaint investigation surveys that were conducted on June 2, 2006 and July 11, 2006. 8. A complaint investigation survey was conducted on June 2, 2006. ‘Based on record review and interview with the Administrator at approximately 12:00 PM on the day of the. survey, it was determined that the facility failed to maintain an up-to-date and accurate medication observation record (MOR) for three of the four current resident records reviewed. The findings include the following. 9. Resident #1 was prescribed Blimite lotion due to a scabies condition. The Administrator stated she assisted the resident several times with this medication and treatment, but did not document or record this assistance when provided in May and June 2006. Facility staff had also signed the June 2006 MOR that the resident was assisted with Albuterol 0.03 1 vial q 6 hours and Ipratropium BR-0.02% 1 vial g 6 hrs. These medications were not available at the facility and the Administrator stated when interviewed that "they were discontinued by the resident's physician". 10. A review of Resident #2's June 2006 MOR revealed the facility staff was signing they assisted this resident with all of his/her medications on 6/1/06 and 6/2/06 - Nifedipine ER 30 mg 1 tab daily; Therms-M tablet 1 daily; Atenolol 100 mg 1 tab BID; Colace 100 mg 1 cap daily; Zestril 20 mg 1 tab BID; Sinemet 1 tab TID; Lorazepam 1 mg-1/2 tab TID; Cogentin 0.5 mg 1 tab HS; Navane 2 mg 1 tab HS while none were available. 11. During an interview at approximately 12:30 PM the Administrator acknowledged the findings. 12 The mandated date of correction was designated as July 2, 2006. 13. A revisit survey was conducted on July 11, 2006. Based on observations made of the facility's medication cart and review of the MOR, resident records, and interview with the Administrator on the day of the survey at approximately 12:30 PM, it was determined the facility failed to maintain an up-to- date and accurate medication observation record (MOR) for three of the six current resident's records reviewed. The findings include the following. 14. The MOR for Resident #4 was not accurate. Resident #4 was being assisted by the facility with Nitro Bid 6.5 mg 1 cap BID. The MOR reviewed for the month of July revealed the facility was only signing for the assistance with the 8 AM dose and not the 8 PM dose every evening from 7/1/06 to 7/10/06. The Administrator changed the MOR during the survey to reflect the twice a day assistance for this time period. 15. The MOR for Resident #3 was. not accurate. Resident #3 was being assisted by the facility with Navane 5 mg 1 cap at bedtime as per physician's order of 7/7/06. The MOR reviewed for the month of duly revealed the facility was signing for assistance with 2 mg of Navane at bedtime for the last two days. 16. The MOR for Resident #5 was not accurate. Resident #5 was being assisted by the facility with Celexa 10 mg 1 tab at bedtime. This medication was discontinued by the resident's physician on 7/7/06. A review of the July MOR for Resident #5 reveals that this medication is signed as assisted by the facility from 7/7/06 to 7/10/06 - four days after the medication was discontinued. This is an uncorrected deficiency from the survey of June 2, 2006. 17. Based on the foregoing facts, Golden Sands Retirement Home violated Rule 58A-5.0185(5)(b), Florida Administrative Code, herein classified as an uncorrected Class III violation. COUNT IT GOLDEN SANDS RETIREMENT HOME FAILED TO ENSURE THAT MEDICATIONS WERE REFILLED IN A TIMELY MANNER. RULE 58A-5.0185(7) (£), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS I VIOLATION 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. A complaint investigation survey was conducted on June 2, 2006. Based on observation, review of the Medication Observation Records, interview with the Administrator and the aide on duty on the day of the survey at approximately 1:30 PM, it was determined that the facility failed to ensure medications were refilled in a timely manner for one of ten current residents sampled. The findings include the following. 20. During a review of the facility's medications and Medication Observation Records it was determined that Resident #2 did not have any of his medications for 6/1/06 and 6/2/06. The Administrator stated she was aware these medications had run out and were not available for this resident. The resident was without these medications - Nifedipine ER 30 mg 1 tab daily; Therms-M tablet 1 daily; Atenolol 100 mg 1 tab BID; Colace 100 mg 1 cap daily; Zestril 20 mg 1 tab BID; Sinemet 1 tab TID; Lorazepam 1 mg-1/2 tab TID; Cogentin 0.5 mg 1 tab HS; Navane 2 mg 1 tab HS. This resident, at approximately 10:40 AM, apparently lost ‘consciousness and fell out of his/her recliner chair, head first onto the tile floor of the living room. The Administrator called 911 as the resident complained that he/she had head pain. 21. The paramedics expressed concern the resident was without his heart, blood pressure and Parkinson's medications for two days. This resident also had several stitches in his head. at the time of this injury. The Administrator stated to the paramedics this resident received these stitches as a result of a fall on approximately 5/22/06 and was taken by 911 to the Emergency Room. It should be noted, when 911 responded, the resident was transported to the hospital by the paramedics for further evaluation. 22. The facility took no action to obtain a supply of this medication and had no documentation available to determine if efforts were made to obtain a new supply or contact was made with the resident's ‘physician to ascertain whether the medication was necessary to the resident's wellbeing. 23. This was confirmed by the Administrator on 6/2/06 at approximately 12:30 PM. 24. Based on the foregoing facts, Golden Sands Retirement Home violated Rule 58A-5.0185(7)(f), Florida Administrative Code, herein classified as a Class I violation, which warrants a revocation of license. COUNT III GOLDEN SANDS RETIREMENT HOME FAILED TO ENSURE THAT MEDICATIONS WERE REFILLED IN A TIMELY MANNER. RULE 58A-5.0185(7) (£), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS I VIOLATION 25. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. A revisit to a complaint investigation survey was conducted on July 11, 2006. Based on observations made of the facility's medication cart, record review of the MOR, resident records, and interview with the Administrator at approximately 12:30 PM, on the day of the survey, it was determined the facility failed to ensure medications were refilled in a timely manner for two of six current residents sampled. The findings include the following. 27. Based on review of the Observation Records it was determined that Resident #4 did not have a supply of Zymar 0.3% eye drops - 1 drop in the left eye four times a day. The Administrator was not able to locate the medication to provide the 12:00 PM dose at the time of the survey. 28. During a review of the facility's medications and Medication Observation Records it was determined that Resident #5 did not have a supply of Levaquin 500 mg 1 tab AM. The resident's physician prescribed the medication on 7/4/06 for ten days. The MOR states the resident was assisted with this medication each day from 7/5/06 to 7/11/06, the day of the survey. The Administrator, however, was not able to locate a supply of this medication to provide the next three days of assistance to complete the prescribed dose of ten tablets. 29. Based on the foregoing facts, Golden Sands Retirement Home violated Rule 58A-5.0185(7) (£), Florida Administrative Code, herein classified as a Class I violation, which warrants a revocation of license. COUNT IV GOLDEN SANDS RETIREMENT HOME FAILED TO PROVIDE PERSONAL SUPERVISION SERVICES AS REQUIRED. RULE 58A-5.01852(1), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE STANDARDS) CLASS I VIOLATION 30. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 31. A revisit to a complaint investigation survey was conducted on July 11, 2006. Based on record review, observation, and interview with the Administrator on the day of the survey at approximately 12:30 PM, it was revealed that the facility is not providing personal supervision .services as required and appropriate for ome of the current eleven residents. The findings include the following. 32. The Administrator, when interviewed stated that the facility is not able to provide adequate supervision for Resident #2 and the other confused and frail residents. Resident #2 returned from the hospital emergency room on 6/2/06, after falling out of a chair during the last survey and injuring his head. He returned to the facility with "slight edema of both hands". 33. The resident required assistance with feeding, ambulation, and all ADLs. On 6/3/06, a note in the resident's record stated the resident "must be fed all of his/her meals due to swollen hands". "No distress noted at this time". on 6/24/06, the Administrator noted the "resident's hands had large open and closed blisters". 34. The resident's family and physician were notified and treatment was ordered to be provided by a home health agency nurse. On 6/27/06 the Administrator noted the resident still continues to go into the bathroom repeatedly and turns on the hot water and runs his hands and feet under it until what appeared to be burns resulted. The facility staff provided no 10 supervision to this resident to prevent these burns. The Administrator, when interviewed stated, "This is an assisted living facility, I can't watch the residents every time they go into the bathroom". All of the current residents require assistance with their ADLs. 35. On 6/29/06 the Administrator noted the resident was so confused that he/she must be closely watched so that he/she would not pull of their dressings. On 7/5/06, the resident was found to be unresponsive and 911 was called. The resident had suffered a stroke and was taken to the hospital. The Administrator took no action to determine and correct the cause of the blisters (the water temperature was found at the time of survey to be 128 degrees) or to provide close assistance and direct supervision of this and the other confused residents to prevent further injury. 36. Based on the foregoing facts, Golden Sands Retirement Home violated Rule 58A-5.0182(1), Florida Administrative Code, herein classified as a Class I violation, which warrants a revocation of license. 11 COUNT V GOLDEN SANDS RETIREMENT HOME FAILED TO ENSURE THAT FACILITY WAS HAZARD FREE AND MAINTAINED TO PROMOTE RESIDENT SAFETY. RULE 58A-5.023(1) (a), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS II VIOLATION 37. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 38. A revisit to a complaint investigation survey was conducted on July 11, 2006. Based on observation and interviews made during tour of the facility accompanied by the administrator, on the day of the survey at approximately 11:30 AM, it was revealed that the facility did not ensure that it was hazard free and maintained to promote resident safety for the eleven confused and frail residents. The findings include the following. 39. During tour of the facility with the Administrator, the following hazardous items were noted: a. An outlet in the hallway outside of the resident's bathroom did not have a cover. The dual outlet was | found to be left exposed. b. The hot water was found to be 128 degrees Fahrenheit and able to severely burn one frail resident's thinning skin (Resident #2). Resident #2 was not being 12 appropriately supervised to prevent burns as a result of the hot wa ter temperature. 40. The Administrator during interview, conducted during tour of .the facility on 7/11/06 at approximately 11:30 AM, _confirmed these findings. 41. The above noted findings represent a direct threat to the physical safety of these confused facility residents : since the Administrator stated close direct supervision is not able to be provided to these confused residents at all times to prevent injury. 42. Based on the foregoing facts, Golden Sands Retirement Home violated Rule 58A-5.023(1) (a), Florida Administrative Code, herein classified as a Class II violation. COUNT VI GOLDEN SANDS RETIREMENT HOME FAILED TO ENSURE PROPER ASSISTANCE WITH THE ADMINISTRATION OF MEDICATION. SECTION 400.4256 (3) (£), FLORIDA STATUTES (MEDICATION STANDARDS) crags IIt VIOLATION 43. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 44. A complaint investigation survey was conducted on June 2, 2006. Based on observation, review of the facility's stored 13 medications, Medication Observation Records and interview with the Administrator and the aide on duty on the day of the survey at approximately 10:30 AM, it was determined that the facility did not provide proper assistance with the administration of medication for all of the ten current residents. The findings include the following. 45. All of the ten current residents are confused and assisted by facility staff with their medications. At approximately 10:30 AM an aide was observed to be signing the MOR for the medications that nine of the ten residents received at approximately 8:00 AM by another aide that was not present or working at the facility at 9:30 AM. The Administrator, when interviewed stated that the aide that assisted the nine ‘residents with their medications "had left the facility". There was no documentation available that this aide was currently working at the facility. The aide on duty was instructed by the Administrator to sign for all of the medications that the other aide had assisted the nine residents with. 46. Resident #1 was prescribed Elimite lotion due to a scabies condition. The Administrator stated she assisted the resident several times with this medication and treatment, but did not document or record this assistance when given. 47. During an interview at approximately 12:30 PM the Administrator acknowledged the findings. 14 48. The mandated date of correction was designated as July 2, 2006. 49. A revisit to a complaint investigation survey was conducted on July 11, 2006. Based on observation, review of the facility's stored medications, Medication Observation Records and interview with the Administrator and the aide on duty on the day of the survey at approximately 10:30 AM, it was determined that the facility did not provide proper assistance with the administration of medication for one of the six current resident records reviewed. The findings include the following. 50. Resident #4 was prescribed Nitroglycerin 6.5 mg cap, 1 cap twice a day. The MOR reflected the resident being assisted once a day at 8 AM. The Administrator stated at approximately 10:30 AM she assisted or a staff member assisted the resident twice a day as prescribed. The Administrator or staff member did not provide proper assistance to this resident with this medication, as a record was not kept for the assistance provided with this medication from 7/1/06 to 7/10/06. This is an uncorrected deficiency from the survey of June 2, 2006. 51. Based on the foregoing facts, Golden Sands Retirement Home violated Section 400.4256(3) (£), Florida Statutes, herein classified as an uncorrected Class III violation. 15 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 Golden Sands Retirement Home on Counts I through VI. 2. Assess a revocation of the assisted living facility license of Golden Sands Retirement Home based on Counts TI through VI for the violations Gited 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 (2006). Specific options for administrative action are set out in the attached Election 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. 16 RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO R REQUEST FOR A HEARING WITHIN TWENTY-ONE ECHIVE A DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLECED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Alba M. Rodriguez, Esq. Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (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) 17 Florida 33166 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 Swaby Davis-Rolle, , Administrator, Golden Sands Retirement Home, 809 N. E. 20% Avenue, Fort Lauderdale, Florida 33304; Swaby Davis, 4765 N. W. 41% Place, Lauderdale, Lakes, Florida 33319 on this a5 ay of Oppose , Oto» = an fodus spite, Alba M. Rodriguez, 18 U.S. Postal Service CERTIFIED MAIL« R (Domestic Mail Only; No Insuran fs, gacd Postage | $ Cartified Fea Roetum Reclept Feo {Endorsement Sita Reatrictad Delivery Feo (Endorsement Required) Total Postage & Faes oe 2410 O01 4235 ( [staat Apt No; ee or PO Box No, U.S. Postal Servicer Cartiflad Fao Retum Reclept Fee (Endorsement Required} Restricted Dellvery Fea {Endorsament Required) 7OOe 2410 O001 4235 3834 PS Form 3800, June 2002 ™ Complete items 1,2 item 4 if Restricted Perea nukes @ Print your name and address‘ai E = | Cc | A . Ata ie can return the ‘card to-yau: we | i iS Card to'the back of the mallpiece,” Of on the front if space permits, 1. Article Addressed to: aise Danio. Aas OY ME AO Gusemy FX-Aate danduds, Fonda (Trarisfer from servideltabey), CERTIFIED MAIL. REC — | re z= OF FEC TA be y auiiite card to me back of the malplece, # ff O> ff p Kigyn & ne WP yf Un etresee of 4 7 COMPLETE THIS SECTION ON DELIVER Y i = L B, Adceived by (Print Nama) » and 3. Also comple Delivery is desired. te | Win D. bs elvery address different from item 1? LI < S, enter delivery address below: C1 No Qrtom A 3. Service Type CO CertiiedMan ] Express’ C1 Registered Qo ihe ee OUnsured Mat C.0.D, Array . / ipt for Merchandise 7002 2410 oony Domestic Retum Receipt UA ntin Com aor SENDER: COMPLETE THIS SECTION (1 Addrassee_| D. Is delivary address different from tam 1¥. 1 Yes If YES, enter delivery address below: [1 No or on the front if space permits. “i 8, Service Type Oi Certified Mall (1 Expjess Mail O Registered C1 Retum Receipt for Merchandise ClInsured Mall (J G.0.D. . * ~ *“tted Deliv Fee, 7002 2420 oooL 4235 3839 eee (Transfer from service label) PS Form 3811, August 2001 Domestic Return Receipt | BAGPRI-O3-2Z-0988 |

Docket for Case No: 07-001262