ay. iOo4 ( STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2007007823 v. ; ‘Return Receipt Requested: 7002 2410 0001 4235 9558 BAYVIEW HOLDINGS, INC., d/b/a BAYVIEW RETIREMENT HOME, Respondent. ADMINISTRATIVE COMPLAINT ; COMES NOW the Agency for Health Care Administration (“AHCA"), by and through the undersigned counsel, and files this Administrative Complaint against Bayview Holdings, Inc. d/b/a Bayview Retirement Home (hereinafter “Bayview , Retirement Home”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes, (2007), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $4,500.00 pursuant to Section 429.19, Florida Statutes (2007), for the protection of the public health, safety and welfare pursuant to Section 429.28(3)(c), Florida Statutes (2007). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Broward County, pursuant to Section 120.57, Florida Statutes and Rule 28-106.207, Florida Administrative Code. 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 (2007), and Chapter 58A-5, Florida Administrative Code. 5. Bayview Retirement Home operates a 12-bed assisted living facility located at 2625 N.E. 13% Court, Fort Lauderdale, Florida 33304. Bayview Retirement Home is licensed as an assisted living facility license number AL10479, with an expiration date of July 12, 2008. Bayview 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 BAYVIEW RETIREMENT HOME FAILED TO ENSURE THAT THE ADMISSION PACKAGE CONTAINED ALL THE REQUIRED COMPONENTS Section 429.41(1) (e), Florida Statutes, and/or Rules 58A-5.024(1) (i), and 58A-5.0181(3), Florida Administrative Code ‘(FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During complaint investigation conducted on 4/30/07 and based on record review and interview with the Administrator on the day of the survey at approximately 11:00 AM, the facility failed to ensure the admission package contained all of the required components. 8. During the Facility Records portion of the survey conducted on 4/30/07, it was noted that the facility's current admission package did not contain all of the required components. The package did not contain: a) A statement of the facility's policy concerning Do Not Resuscitate Orders and Advanced Directives. b) A copy of the facility's resident elopement response policies and procedures. 9. During an interview at approximately 12:00 PM the Administrator acknowledged the findings. Mandated Correction Date: 5/31/07. 10. During the revisit conducted on 6/20/07 and based on record review and interview with the Administrator and aide on duty, on the day of the survey at approximately 11:00 AM, the facility failed to ensure the admission package contained all of the required components. 11. During the Facility Records portion of the survey conducted on 6/20/07, it was noted that the facility's eee ey current admission package did not contain all of the required components. The package did not contain: a) A statement of. the facility's policy concerning Do Not Resuscitate Orders and Advanced Directives. b) A copy of the facility's resident elopement response policies and procedures. 12. During an interview at approximately 12:00 PM, the Administrator acknowledged the findings and stated the facility did not have the above policies and procedures. This is an uncorrected deficiency from the 4/30/07 survey report. 13. Based on the foregoing, Bayview Retirement Home violated Section 429.41(1)(e), Florida Statutes, and/or Rules 58A-5.024(1) (i), and. —sS8A-5.0181(3), — Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00. COUNT II BAYVIEW RETIREMENT HOME FAILED TO ENSURE THAT THERE WAS A CURRENT SATISFACTORY FIRE INSPECTION Section 429.41(1) (a)l.m., Florida Statutes, and/or Rule 58A- 5.015(1) (a)3, Florida Administrative Code (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. During the complaint investigation conducted on 4/30/07 and based upon record review and interview with the Administrator on the day of the survey, the facility did not ensure that there was a current and satisfactory fire inspection. 16. The Administrator, when requested by the surveyor was unable to produce a current satisfactory fire inspection. The last fire department inspection was conducted on 4/27/07 and was classified as not satisfactory. 17. The Administrator, during interview conducted at approximately 12:00 PM on the date of this survey, confirmed this finding. Mandated Correction Date: 5/31/07 18. During the revisit conducted on 6/20/07 and based upon record review and interview with the Administrator on the day of the survey, the facility did not ensure that there was a current satisfactory fire inspection. 19. The Administrator, when requested by the surveyor was unable to. produce a " current satisfactory . fire inspection. The last fire department inspection was conducted on 5/18/07 and was classified as not satisfactory. 20. The Administrator, during interview conducted at approximately 12:00 PM on the date of this survey, confirmed this finding. This is an uncorrected deficiency from the 4/30/07 survey report. 21. Based on the foregoing, Bayview Retirement Home violated Section 429.41(1)(a)l.m., Florida Statutes, and/or Rule 58A-5.015(1) (a)3, Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00. COUNT III BAYVIEW RETIREMENT HOME FAILED TO DEVELOP ELOPEMENT POLICIES AND PROCEDURES Rule 58A-5.024(1)(q), Florida Administrative Code (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 22. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. During the complaint investigation conducted on 4/13/07 and based upon record review and interview with the Administrator, on the day of the survey at approximately 11:30 AM, the facility did not develop elopement policies and procedures for this facility. The facility's current records did not address this. issue. 24. The facility did not formulate and document policies and procedures to address a resident elopement or the procedures to be followed by staff in the event of a resident elopement. The 6 current residents of the facility were all found, upon interview to be confused and diagnosed with Dementia. This was confirmed by the Administrator of the facility at approximately 11:30 AM on the day of the survey. Mandated Correction Date: 5/31/07 25. During the revisit conducted on 6/20/07 and based upon record review and interview with the Administrator and aide on duty, on the day of the survey at approximately 11:30 AM, the facility did not develop elopement policies and procedures for this facility. The facility's current records did not address this issue. 26. The facility did not formulate and document policies and procedures to address a resident elopement or the procedures to be followed by staff in the event of a resident elopement. The 6 current residents of the facility were all found, upon interview to be confused and diagnosed with Dementia. This was confirmed by the Administrator of the facility at approximately 11:30 AM on the day of the survey. This is an uncorrected deficiency from the 4/30/07 survey report. 27. Based on the foregoing, Bayview Retirement Home violated Rule 58A-5.024(1) (q), Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00. COUNT IV BAYVIEW RETIREMENT HOME FAILED TO CONDUCT ELOPEMENT PREVENTION AND RESPONSE DRILLS Sections 429.41(1) (a)3. and 429.41(1) (1), Florida Statutes, and/or Rule 58A-5.0182(8)(c), Florida Administrative Code (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS IIT 28. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. During the complaint investigation conducted on 4/30/07 and based upon record review and interview with the Administrator, on the day of the survey at approximately 11:30 AM, the facility did not conduct elopement prevention and response drills. 30. The facility never conducted an elopement and response drill. The Administrator, upon interview, at approximately 11:30 AM, stated that she was aware of the requirement to conduct two drills per year as of June 2004 but had not conducted and documented any drills. This was confirmed by the Administrator at approximately 11:30 AM on the day of the survey. Mandated Correction Date: 5/31/07 31, During the revisit conducted on 6/20/07 and based upon record review and interview with. the Administrator and aide on duty, on the day of the survey at approximately 11:30 AM, the facility did not conduct elopement prevention and response drills. 32. The facility never conducted an elopement and response drill. The Administrator, upon ' interview, at approximately 11:30 AM, stated that she was not aware of the requirement to conduct two drills per year as of June 2004 and had not conducted and documented any drills. This was confirmed by the Administrator at approximately 11:30 AM on the day of the survey. This is an uncorrected deficiency from the 4/30/07 survey report. 33. Based on the foregoing, Bayview Retirement Home violated Sections 429.41(1)(a)3, and 429.41(1) (1), Florida Statutes, and/or Rule 58A-5.0182(8) (c), Florida - Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00. COUNT V BAYVIEW 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 II VIOLATION 34. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 35. During a revisit conducted on 6/20/07 and based on based on record review and interview with the Administrator, at approximately 11:00 AM on the day of the survey, it was determined that the facility failed to maintain an accurate Medication Observation Record (MOR) for three of six current resident records reviewed. The assisting of residents with medications and not maintaining an accurate record, directly threatens the physical health of these residents. 36. A review of the June 2007 MOR and medications for Resident #1 revealed that the resident was prescribed Pericolace 1 tab BID. The Medication Observation Record (MOR) for this resident stated 1 tab PRN. The resident was only being assisted with this medication 1 tab daily. This resident was also prescribed Furosemide 40 mg, 2 tab daily, while the MOR stated 40 mg 2 tabs BID. The resident was also prescribed Cosopt 0.5%, 2 drops in each eye BID on the last physician's order dated 12/06, the resident was being assisted with 1 drop in each eye. 37. A review of the June 2007 MOR and medications for Resident #4 revealed that the resident was prescribed Verapamil 240 mg 1 tab daily. The Medication Observation Record (MOR) stated 25 mg. 38. A review of the June 2007 MOR and medications for Resident #6 revealed that the resident was prescribed Loratadine 10 mg, 1 tab PRN and being assisted when needed per the Administrator when interviewed. This medication was not listed on the MOR. This resident was. also prescribed Zoloft 100 mg, 1 tab daily. The MOR for this resident did not include the strength of the medication. . 39. The absence of accurate documentation of the medication assistance as prescribed by the residents' physicians directly threatens the physical health of these residents. 40. This was confirmed by the Administrator on 6/20/07 at approximately 12:30 PM. This deficiency was previously cited during the complaint investigation conducted on 4/30/07 41. Based on the foregoing, Bayview Retirement Home violated Rule 58A-5.0185(5) (b), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $2,000.00. COUNT VI BAYVIEW RETIREMENT HOME FAILED TO ENSURE THAT ALL OVER THE COUNTER DRUGS WERE PROPERLY LABELED Rule 58A~5.0185(8) (b), Florida Administrative Code (MEDICATION STANDARDS) UNCORRECTED CLASS III VIOLATION 42. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 43. During the complaint investigation conducted on 4/30/07 and based upon observations made of the facility's medication storage and record review of the MOR, resident records, and interview with the Administrator on the day of the survey, at approximately 11:30 AM, it was revealed that the facility did not ensure that all centrally stored over- the-counter (OTC) drugs were properly labeled for one of the five current residents being assisted with medication. 44. The facility was found to be centrally storing a small round plastic container for Resident #4 that was hand labeled with Multi-Vitamins and Bé vitamins, written on a label on the lid. There was no MOR for this resident. The 11 plastic container was labeled with resident's name and the above information. It did not have the manufacturer's label with directions for use. The facility had no documentation to indicate that any efforts were made to notify the resident's representative or physician that this was not permitted and to obtain a properly labeled supply. This was confirmed by the Administrator on 4/30/07, at approximately 12:00 PM. Mandated Correction Date: 5/31/07 45. During the follow-up conducted on 6/20/07 and based upon observations made of the facility's medication storage and record review of the MOR, resident records, and interview with the Administrator and an aide on duty, on the day of the survey, at approximately 11:30 AM, it was revealed that the facility did not ensure that all centrally stored OTC drugs were properly labeled for one of the six current residents being assisted with medication. 46. The facility was found to be centrally storing an. unlabeled bottles of Tylenol, B-12 vitamins, and Metamucil tablets for Resident #6. The bottles of these OTC medications were not labeled with resident's name and the dosage information. The facility had no documentation. to indicate that any efforts were made to notify the resident's representative or physician that this was not permitted and to obtain a properly labeled supply. This was confirmed by —— the Administrator on 6/20/07 at approximately 12:00 PM. This is an uncorrected deficiency from the 4/30/07 survey report. 47. Based on the foregoing, Bayview Retirement Home — violated Rule 58A-5.0185(8) (b), Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $500.00. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I through VI. B. Assess an administrative fine of $4,500.00 against Bayview Retirement Home on Counts I through VI pursuant to Sections 429.19, and 429.28(3) (b) and 429.28(3)(c), Florida Statutes. Cc. 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 (2007). Specific options for administrative action are set out in the attached Election of Rights Form. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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 . ORDER BY THE AGENCY . ia Lawton~-Russell Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52°? Terrace Suite 103 Miami, Florida 33166 Copies. furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (U.S. Mail) Finance and Accounting Revenue and Management Unit Agency for Health Care Administration 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 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 Alice Rothman, Administrator and Registered Agent, Bayview Retirement Home, 625 N.E. 13" Court, Fort Lauderdale, Florida 33304 on 22 , 2008. 15 COMPLETE THIS SECTION ON DELIVERY 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 if space permits. 1, Article Addressed to, 3. Service Type Certified Mall C1 Express Mail Ci Registered [iFleturn Receipt for Merchandise O Insured Mail = C.0.D. - 4. Restricted Delivery? (Extra Fee) Oyes 2. Article Number (ranster trom S€PVere- rare ?od2 2410 O00 4235 9558 PS Form 381 1, February 2004 Domestic Return Receipt 102595-02-M-1 FT Kervkrdate,, PO Brey

Docket for Case No: 08-001044

Orders for Case No: 08-001044