Certified Mail Receipt ; (7004 1160 0003 3739 9227) BY STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR YU y y HEALTH CARE ADMINISTRATION, O/ ‘NY « Petitioner, AHCA NO.: 2007009590 VS. A-DORA INC. d/b/a MAYFLOWER, THE, Respondent. —~--------------------_/ ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against A-Dora. Inc. d/b/a Mayflower, The (hereinafter “Mayflower, The”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2007), alleges: NATURE OF THE ACTION 1. This is an action to impose two (2) administrative fines in the amount of One Thousand Dollars ($2,000.00), against Mayflower, The for two (2) class II deficiencies, pursuant to Section:429.19(2)(b), Fla. Stat. (2007) and Sections 58A-5.0185(3\a), 58A- 5.0185(3)(b), Fla. Admin, Code (2007). JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 429, Part 1 and Section Sections 120.569 and 120.57, Fla. Stat. (2007). c - 3. Venue lies in Alachua County, High Springs, Florida, pursuant to Section 120.57 Fla. Stat. (2007); Rule 58A-5, Fla. Admin. Code (2007) and Section 28.106.207, Fla, Stat. (2007). a 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, Fla. Stat., and Rule 58A-5, Fla. Admin. Code (2007). 5. Mayflower, The is a for-profit corporation, whose 15-bed assisted living facility is located at 725 NW Santa Fe Boulevard, High Springs, Florida 32655. Mayflower, The is licensed as an assisted living facility license # AL9545; certificate number #23181, effective July 2, 2007 through May 25, 2009. Mayflower, The was at all times material hereto, licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I MAYFLOWER, THE FAILED TO ASSURE THAT ONE OF TWO EMPLOYEES (#1) WAS TRAINED TO ASSIST RESIDENTS WITH SELF ADMINISTRATION OF THEIR MEDICATIONS. FAILURE TO ENSURE EMPLOYEES ARE PROPERLY ’ TRAINED MAY RESULT IN MEDICATION ERRORS. STATE TAG A609-MEDICATION STANDARDS Section 429.19(2)(, Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Rule 58A-5.0185(3)(a), Fla. Admin. Code (2007) MEDICATION PRACTICES 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. wa ( } f 7. On or about July 9, 2007, AHCA conducted an unannounced complaint investigation survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a. On or about July 9, 2007, Mayflower, The failed to assure that one of two employees (#1) was trained to assist residents with self administration of their medications. ‘Failure to ensure employees are properly trained may result in medication errors. The Findings include: Review of the facility's Medication Observation Records (MORs) revealed only two sets of initials documented, which pertained to the administrators and employee #2, However, interviews with resident #1 on 7/9/07 at 10:30 AM and resident #2 on 1/9/07 at 10:45 AM revealed that employees #1, #4 and the administrator's son-in- law has given them their medications. Review of employee #1's personnel file failed: to reveal. the required 4 hours of medication training. Review of the provided schedule for June 2007, revealed that employee #1 worked alone on Sundays for the month of June from 7 AM to 6 PM, which involved two medications passes the 8 AM and 5 PM, but the administrator's initials are documented on the MOR indicating that she gave the medications. On 7/9/07, at 12:30 PM, interview with the administrator revealed that "l am always here, 1 gave the medications, he does not give the medications." On 7/9/07, at 2:30 PM, interview with the administrator revealed that she denied anyone giving medications to the residents other than herself and employee #2. Further discussion revealed that she prepares the medications in pill cups and may have had the employees hand the cups to the residents. 8. The regulatory provisions of the Fla. Stat. (2007), that are pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds. ~ (2)(b) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class 1 violations. The agency shall impose an administrative fine for a cited class ll violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. * oe ok 464.003 Definitions- (3)(a)2 the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 58A-5.0185 Medication Practices, (3)(a) For facilities which provide assistance with self-administered medication, either: a nurse; or an unlicensed staff member, who is at least 18 years old, trained to assist with selfadministered medication in accordance with Rule 58A-5.0191, F.A.C., and able to demonstrate to the administrator the ability to accurately read and interpret a prescription label, must be available to assist residents with self- administered medications in accordance with procedures described in Section 429.256, F.S. ek # 9. The violation alleged herein constitutes a class 1] deficiency, and warrants a fine of $1,000.00 WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint: 2. Impose a fine in the amount of $1,000.00 COUNT IL MAYFLOWER, THE FAILED TO ASSIST 1 of 2 (#2) SAMPLED RESIDENTS MEDICATION REVIEWED, WITH THEIR MEDICATIONS AS PRESCRIBED BY THE PHYSICIAN. FAILURE TO ASSIST RESIDENTS TAKE THEIR MEDICATIONS AS ORDERED BY A PHYSICIAN HAS THE POTENTIAL FOR THE RESIDENTS’ MEDICAL CONDITION TO GET WORSE. STATE TAG A610-MEDICATION STANDARDS Section 429.19(2)(b), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Rule 58A-5,.0185(3)(b), Fla. Admin. Code (2007) MEDICATION PRACTICES 10. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 11. On or about July 9, 2007, AHCA conducted an unannounced complaint investigation survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a. On or about July 9, 2007, Mayflower, The failed to assist. 1 of 2 (#2) sampled residents medication reviewed, with their medications as prescribed by the physician. Failure to assist residents take their medications as ordered by a physician has the potential for the residents’ medical condition to get worse. The Findings include: Observation of medications revealed that resident #2 has a bottle of Lisinopril 10 milligrams (mg), with instructions to take 1/2 tablet every day. The label stated that 30 tablets had been dispensed and filled on 6/25/07. Further observation of the medications with in this bottle revealed 37 half tablets, as well as bits and pieces in the bottle. By calculating the day the medication was dispensed and the number of 1/2 tablets the resident should have consumed by the day of the investigation, it was determined that the resident should have had 46 half tablets remaining in the bottle. On 7/9/07, at 11:30 AM, interview with employee #2 and the administrator revealed they are the ones that break the tablets for the residents. Review of this resident's records failed to reveal any documentation that the facility had notified the pharmacist or the physician regarding the problem breaking the resident's tablet in half. 12. The regulatory provisions of the Fla. Stat. (2007), that are pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds. ~ (2)(b) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class 1- violations. The agency shall impose an administrative fine for a cited ‘class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation, kk Oe 464.003 Definitions~ (3)a)2 the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. ‘ 58A-5.0185 Medication Practices. ~ (3)(b) Assistance with self-administration of medication includes verbally prompting a resident to take medications as prescribed, retrieving and opening a properly labeled medication container, and providing assistance as specified in Section 429.256(3), F.S. In order to facilitate assistance with selfadministration, staff may prepare and make available such items as water, juice, cups, and spoons. Staff may also return unused doses to the medication container. Medication, which, appears to have been contaminated, shall not be returned to the container. + oe Ok 13. The violation alleged herein constitutes class II deficiency, and warrants a fine of $1,000.00 { WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2 Impose a fine in the amount of $1,000.00 Respectfully submitted this Florida. Wa =\IVAN RICA waa’ Michael O. Mathis Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 : 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office): (850) 921-0158 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Fla. Stat. (2007). 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 the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney, Telephone (850) 922-5873. RESPONDENT 18 FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND-‘THE ENTRY OF A-FINAL ORDER BY THE AGENCY, CERTIFICATE OF SERVICE 1 HEREBY CERT FY that a true ny correct “COPY of the regen has been served by certified mail on Ye day of x Oetab el Mayflower, The, 725 NW Santa Fe Blvd., High Spring, Florida 32655. (vavilyr Wo Michael O. Mathis, Esq. [A/G FFICIAL USE Carilflad Fee fleturn Reclapt Fee (Endorsemant Required) Restrictad Dellvery Fea (Endorsement Requirad) Total Postage & Fees | Seren Pulse, Redman. wom 138 NW. Ganka Fe. Bh 7004 ULbO 0003 3739 Acel Zh COMPLETE THIS SECTION ON DELIVERY. = Complete items 1, 2, and 3. Also complete A. Signature Item 4 If Restricted Delivery is desired. C1 Agent M Print your name and address on the reverse XA Qn ( Addressee so that we can return the card to you. B, Received by ( Printed N: . ® Attach this card to the back of the mailpiece, + Received! by ( Printed Nama) G. Date of Delivery or on the front if space permits. 10; 2d) ( i ] D, {Is delivery address different from item 1? (Cl Ye lf YES, anter delivery address below: 1 No QO~Y . Sayles Type Certified Mail 1 Express Mail (1 Registered (I Return Receipt far Merchandise C1 Insured Mail C} €.0.0, |. Restricted Delivery? (Extra Fee) 2. Article Number (Transfer from service label) 7004 160 0003 3739 4eel i eens PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1035

Docket for Case No: 07-005428