ertified Mail STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NOS.: 2008000148 vs. 2008000152 CASO, INC. d/b/a PARADISE MANOR II, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Caso, Inc. d/b/a Paradise Manor II (hereinafter “Paradise Manor II”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2007), alleges: ; NATURE OF THE ACTION 1. This is an action to impose five (5) administrative fines in the amount of Four Thousand Five Hundred Dollars ($4,500.00), against Paradise Manor II for five (5) “uncorrected class III deficiencies, pursuant to Sections 429.19(2)(c), and 429.52(4), Fla. Stat. (2007) and Sections 58A-5.0181(2)(b), 58A-5.0185(4)(a), 58A-5.0185(5)(b), 58A- 5.0185(7)(f), and 58A-5.0191(1)(c), Fla. Admin. Code (2007). C Recenpt «=: (7004 2890 0000 5527 3688 ) — ao -o = x 2 a JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 429, Part 1 and Sections 120.569 and 120.57, Fla. Stat. (2007). 3. Venue lies in Volusia County, Port Orange, Florida, pursuant to Section 120.57 Fla. Stat. (2007); Rule 58A-5, Fla. Admin. Code (2007) and Section 28.106.207, Fla. Stat. (2007). 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 Rules 58A-5, Fla. Admin. Code (2006). 5. Paradise Manor Il is a for-profit corporation, whose 6-bed assisted living facility is located at 435 GreenLeaf Square, Port Orange, Florida 32127. Paradise Manor Il is licensed as an assisted living facility license # AL9904; certificate number #21283, effective September 1, 2006 through August 31, 2008. Paradise Manor II 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 1 PARADISE MANOR II FAILED TO ENSURE THAT HEALTH ASSESSMENTS WERE COMPLETED WITHIN 60 DAYS PRIOR TO ADMISSION OR WITHIN 30 DAYS AFTER ADMISSION FOR TWO OF FIVE RESIDENTS REVIEWED. STATE TAG A418-ADMISSIONS CRITERIA STANDARDS Section 429.19(2)(c), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Rule 58A-5.0181(2)(b), Fla. Admin. Code (2007) RESIDENCY CRITERIA AND ADMISSION PROCEDURES 6. AHCA tealleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about December 4, 2007, AHCA conducted a third follow-up appraisal visit at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a. On or about July 3, 2007, Paradise Manor I! failed to have a medical examination completed within 30 days after admission recorded on the AHCA Form 1823, January 2006 for 1 of 7 residents (Resident #1). A medical examination is crucial for the health of a resident to ensure care and services are provided for the resident as needed. b. During a second follow-up survey on or about September 26, 2007, Paradise Manor II failed to ensure that health assessments were completed within 60 days prior to. admission or within 30 days after admission for two of five residents reviewed. c. During a third follow-up survey on or about December 4, 2007, Paradise Manor II failed to ensure that health assessments were completed within 60 days prior to admission or within 30 days after admission for two of five residents reviewed. The Findings include: A review of records for Residents #3 and #6, revealed that Resident #3 was admitted in October of 2007 and the only health assessment in the record was not complete, not dated and not signed by a health care provider. Resident #6 was * admitted on June 22, 2007 and the health assessment was dated October 22, 2007: The health assessment had three different dates for when the health assessment was completed. Due to the inconsistency of dates and times, it was not possible to determine the accuracy of the assessment. The administrator confirmed this information in an interview on December 4, 2007 at 3:30 P.M. This deficiency was previously cited on September 26, 2007. Class III Correction Date: 1/04/2008 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)(c) Class "III" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class HI violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense. a 58A-5.0181 Residency Criteria and Admission Procedures. (2)(b) Medical examinations completed after the admission of the resident to the facility must be completed within 30 days of the date of admission and must be recorded on the Resident Health Assessment for Assisted Living Facilities (ALF), AHCA Form 1823, January 2006, which is incorporated by reference. A faxed copy of the completed form is acceptable. A copy of AHCA Form 1823 may be obtained from the Agency Central Office or its website at www.fdhc state.fl.us/MCHQ/Long_Term_Care/Assisted_living/ pdf/AHCA_For m_1823%_Jan_2006_.pdf. Previous versions of this form completed up to six (6) months after 7-30-06 are acceptable. * oe OK 9. The violation alleged herein constitutes an uncorrected class Il 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 II PARADISE MANOR II FAILED TO ENSURE THAT THE ADMINISTRATOR HAS COMPLETED 12 HOURS OF CONTINUING EDUCATION IN TOPICS RELATED TO ASSISTED LIVING EVERY TWO YEARS. STATE TAG A505-STAFFING STANDARDS Section 429.19(2)(c), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Section 429.52(4), Fla. Stat. (2007) Rule 58A-5.0191(1)(c), Fla. Admin. Code (2007) STAFF TRAINING REQUIREMENTS AND COMPETENCY TEST 10. | AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set. - forth herein. 11. On or about December 4, 2007, AHCA conducted a third follow-up appraisal visit at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about July 3, 2007, Paradise Manor II failed to ensure that the administrator has completed 12 hours of continuing education related to Assisted Living every two years. b.) During a second follow-up survey on or about September 26, 2007, Paradise Manor II failed to ensure that the administrator has completed 12 hours of continuing education related to Assisted Living every two years. o) During a third follow-up survey on or about December 4, 2007, Paradise Manor I] failed to ensure that the administrator has completed 12 hours of continuing education related to Assisted Living every two years. The Findings include: A review of the administrator's employee record revealed that there was no documentation of continuing education since June of 2005. The administrator in an interview on December 4, 2007 at 3:30 P.M., concurred that 12 hours of continuing education has not been completed in the last two years. Based on a review of the administrator's employee record, there was no documentation of a change of administrator's or that the owner had retaken the core training and successfully passed the certification examination. The administrator was unable to ~ provide the documentation of training and successful completion of the certification test. This was previously cited on September 26, 2007. Class III Correction Date: 1/04/2008 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)(c) Class "IIT" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense. ee Ok 429.52 Staff training and educational programs; core educational requirement.~ (4) Administrators are required to participate in continuing education for a minimum of 12 contact hours every 2 years. ee 58A-5.0191 Staff Training Requirements and Competency Test. (1)(c) Administrators and managers shall participate in 12 hours of continuing education in topics related to assisted living every 2 years as provided under Section 429.52, FS. 13. The violation alleged herein constitutes an uncorrected class III 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 PARADISE MANOR II FAILED TO PROVIDE LICENSED PERSONNEL TO PERFORM BLOOD SUGAR TESTING FOR RESIDENT #7, 1 OF 7 SAMPLED RESIDENTS. THIS MAY LEAD TO INAPPROPRIATE TESTING AND CAUSE DIABETES COMPLICATIONS. THIS WAS PREVIOUSLY CITED ON 9/26/07. STATE TAG A613-MEDICATION STANDARDS Section 429.19(2)(c), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF _ ADMINISTRATIVE FINES; GROUNDS Section 429.52(4), Fla. Stat. (2007) Rule 58A-5.0185(4)(a), Fla. Admin. Code (2007) MEDICATION PRACTICES 14. | AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. On or about December 4, 2007, AHCA conducted a third follow-up monitoring visit at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about September 26, 2007, Paradise Manor II failed to provide a staff member who is licensed to perform blood sugar tests for 1 of 5 sampled residents. An unlicensed staff member without a physician’s order performed a blood sugar test on this resident which may have caused undue harm to the resident. b.) During a third follow-up survey on about December 4, 2007, Paradise Manor II failed to provide licensed personnel to perform blood sugar testing for Resident 37, 1 of 7 sampled residents. This may lead to inappropriate testing and cause diabetes. The Findings include: | While looking through the medication drawer for Resident #7, a blood sugar monitoring device was observed. The medical record was reviewed and a physician's order was not seen to perform blood sugar tests. A staff member (non-licensed personnel) was interviewed on 12-4-07 at 2:30 p.m. who stated that she assisted the resident with performing blood sugar tests daily. Resident #7 on 12-4-07 at 2:45 pm confirmed that non-licensed personnel did the blood sugar testing for him/her because s/he was unable to do so due to left sided weakness. Class HI Correction Date: 12-7-07 (Immediate) 16. 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)(c) Class "HI" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class II] violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense. * oe OF 58A-5.0185 Medication Practices. (4)(a) For facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a health care provider’s order or prescription label. x ek 17. The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $500.00. 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 $500.00 COUNT IV PARADISE MANOR II FAILED TO MAINTAIN UP-TO-DATE MOR’S FOR 2.OF 7 SAMPLED RESIDENTS, RESIDENTS #2 AND #7. THIS WAS PREVIOUSLY CITED ON 9/26/07. STATE TAG A615-MEDICATION STANDARDS Section 429,19(2)(c), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Rule 58A-5.0185(5)(b), Fla. Admin. Code (2007) MEDICATION PRACTICES 18. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. On or about December 4, 2007, AHCA conducted a third follow-up monitoring visit at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about May 2, 2007, Paradise Manor I] failed to maintain a daily medication observation record (MOR) for each resident who receives assistance with self- administration of medications or medication administration for 1 of 2 residents (Resident #1). This could lead to improper assistance with mediations. b.) On or about July 3, 2007, Paradise Manor II failed to maintain a daily medication observation record (MOR) for July 2007 for 4 of 7 residents (Resident #3, #4, #6, #7, and #2). This‘could cause serious medication errots for these residents and could be detrimental to the residents’ health status. This was previously cited on May 2, 2007. c.) During a second follow-up survey on or about September 26, 2007, Paradise Manor II failed to maintain a daily medication observation record (MOR) in September 2007 for 4 of 5 sampled residents (Resident 1, #2, #3, and #5). This could cause serious medication errors for these residents and could be detrimental to the residents’ health status. This was previously cited on July 3, 2007. d.) During a third follow-up survey on or about December 4, 2007, Paradise Manor I] failed to maintain up-to-date MOR s for 2 of 7 sampled residents, Residents #2 and #7. This was previously cited on 9/26/07. The Findings include: 1. The December 2007 MOR for Resident #2 revealed Warfarin 7.5 mg tablet, take one tablet by mouth every other day. The MOR for December 1* and 2™ had an "X" marked in them. Staff was interviewed on 12-4-07 at 11:15 a.m. who stated that the medication was not given on those days despite the physician order because a different dose was given on those days. Staff confirmed that the MOR for this medication revealed it was to be given everyday. 2. The November 2007 MOR for Resident #7 revealed Morphine Sulfate 30 mg, 1 tablet every 12 hours. Two of the dates, November 29 at 8 pm and November 30" at 8 am and 8 pm did not have staff signatures that the resident was assisted by staff. Another medication, Ranitidine 150 mg was not signed off on November 29th at 8 pm. Another medication, Naproxen was not signed on November 29th at 8 pm. The staff member who was working those shifts confirmed these omissions in an interview on 12-4-07 at 10 a.m. Class Il Correction Date: 12-7-07 (Immediate) 10 20. 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. ~ (2c) Class "III" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class II] violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense. * Ok ok 58A-5.0185 Medication Practices. (5)(b) (b) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. kok x 21. The violation alleged herein constitutes an uncorrected class III 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 V PARADISE MANOR II FAILED TO REFILL PRESCRIPTIONS IN A TIMELY MANNER FOR 1 OF 7 SAMPLED RESIDENTS, RESIDENT #6. THIS WAS PREVIOUSLY CITED ON 7/3/07 AND 9/26/07. STATE TAG A631-MEDICATION STANDARDS Section 429.19(2)(c), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Rule 58A-5.0185(7)(f), Fla. Admin. Code (2007) MEDICATION PRACTICES 22. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23, On or about September 26, 2007, AHCA conducted a third follow-up monitoring visit at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about July 3, 2007, Paradise Manor II failed to refill medications in a timely manner for 3 of 7 (Residents #4, #3, #1) residents and obtain medications for Resident #7 who was admitted the previous day. b.) During a second follow-up survey on or about September 26, 2007, Paradise Manor II failed to refill medications in a timely manner for 1 of 5 sampled residents. This was previously cited on July 3, 2007. c.) During a third follow-up survey on or about September 26, 2007, Paradise Manor II failed to refill prescriptions in a timely manner for 1 of 7 sampled residents, Resident #6. This was previously cited on 7/3/07 and 9/26/07. 12 The Findings include: The 2007 MORs for Resident #6 revealed that s/he received his/her morning medications on December 4, 2007. The MORs were in the active file along with the other residents’ MORs. The Administrator on 12-4-07 at 10:45 a.m. was asked for the medications for Resident #6. She stated that she did not have any. She stated that the daughter took them today because the resident was to be discharged today. The resident's belongings still resided in the facility and there was no documentation that the resident was discharged. Class III Correction Date: December 7, 2007 (Immediate) 24. 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)(c) Class "III" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class Il violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense. + ok * 58A-5.0185 Medication Practices. (7)(f) The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with selfadministration of medication or medication administration are filled or refilled in a timely manner. sk Ok 25. The violation alleged herein constitutes an uncorrected 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 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 Count’s I, I, HI, IV, V. 2. Assess against Paradise Manor II an administrative fine in the amount of $4,500.00 for the violation cited above. 3. 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 Section 120.569, Florida Statutes (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. RESPONDENT IS 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. 14 — Florida, NNAN ART AWata avs) 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) CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been served Michael ©. Mathis, Esq. 15 x a s(a = So ru & os Ss . (peunbey juewesiopus) 1 x. & eq Aanieg pense aes a1ey (pesnbers weuesiopug) aN ee4 idje0ey uiMeL o SRY tol : Spey — & SOS Co od uw SS & _ oy |" = CUOs SdSrcMma je SUSOM JNO JISIA-UONEULOUT ALaAt|ap JOG ‘ ua (PapIAdld abe IahOD eouPinsiy ON *AjuO lew onsawog) T= ley. 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Docket for Case No: 08-000819