eff ; STATE OF FLORIDA O89 mE Sp /4 o AGENCY FOR HEALTH CARE ADMINISTRATION —_— : Aplin, EY 9 AGENCY FOR HEALTH CARE O¥-S14 . : now ADMINISTRATION, NeapThae O53 VE Petitioner, AHCA No.: 2007011988 s v. Return Receipt Requested: 7004 2890 0000 5525 9303 FLORIDA HOUSING CORPORATION, d/b/a 7004 2890 0000 5525 9310 PALM BEACH ASSISTED LIVING FACILITY, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Florida Housing Corporation, d/b/a Palm Beach Assisted Living Facility (hereinafter “Palm Beach Assisted Living Facility”), 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 $12,000.00 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 Palm Beach County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative 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. Palm Beach Assisted Living Facility operates a 200-bed assisted living facility located at 534 Datura Street, West Palm Beach, Florida 33401. Palm Beach Assisted Living Facility is licensed as an assisted living facility license number AL7617 with an expiration date of December 20, 2008. Palm Beach Assisted Living Facility 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 IL PALM BEACH ASSISTED LIVING FACILITY FAILED TO MAINTAIN AN ACCURATE AND UP-TO-DATE MEDICATION OBSERVATION RECORD (MOR) FOR ALL RESIDENTS Rule 58A-5.0185(5) (b), Florida Administrative Code (MEDICATION STANDARDS) UNCORRECTED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the Spot Check Appraisal Survey conducted on 6/19/07 and based on record review and interview, it was determined that the facility failed to maintain an accurate and up-to-date Medication Observation Record (MOR) for 2 out of 4 sampled resident MOR's reviewed (Resident #'s 2 and 3). 8. During an interview with the Director of Personal Care on 06/19/07 at approximately 1:00 PM, it was revealed that Resident #'s 2 and 3 both receive assistance with their medications from facility staff. 9. During a review of Resident #2's Medication Observation Record dated June 2007, it was revealed that the MOR documented the following order: a) The MOR read: Methadone HCL 40 mg. Take 1 tablet by mouth 3 times a day and 2 tablets at bedtime. During a review of Resident #2's Individual Resident Control Drug Medication Observation Record it was revealed that the record documented that the facility received 60 tablets of the resident's aforementioned medication from the pharmacy on 06/15/07. Upon further review of the "Individual Resident Control Drug Record" it was noted that the record documented that the resident consumed 15 of the tablets from 06/15/07 to 06/19/07. The record documented that the facility had a 44 count supply of this medication on hand. However, during the medication review, it was noted that the facility actually had a total count of 160 tablets of the Methadone on hand. b) The MOR read: Oxycodone HCL 30 mg. Take 1 tablet by mouth every 6 hours as needed for pain. During a review of Resident #2's Individual Resident Control Drug Medication Observation Record it was revealed that the record documented that the facility received 19 tablets of the resident's aforementioned medication from the pharmacy on 06/15/07. Upon further review of the "Individual Resident Control Drug Record" it was noted that the record documented that the resident consumed 10 of the tablets from 06/15/07 to 06/19/07. The record documented that the facility had an 8 count supply of this medication on hand. However, during the medication review, it was noted that the facility actually had a total count of 5 tablets of the Oxycodone on hand. 10. During a review of Resident #3's Medication Observation Record dated June 2007, it was revealed that the MOR documented the following order: a) The MOR read:. Lorcet 10/650. Take 1 tablet by mouth 4 times a day. During a review of Resident #3's Individual Resident Control Drug Medication Observation Record it was revealed that the record documented that the facility received 30 tablets of the resident's aforementioned medication from the pharmacy on 06/09/07. Upon further review of the "Individual Resident Control Drug Record" it was noted that the record documented that the resident consumed 23 of the tablets from 06/09/07 to 06/16/07.. The record documented that the facility had a 6 count supply of this medication on hand. However, during the medication review, it was noted that the facility actually had a total count of 18 tablets of the Lorcet on hand. 11. During a further interview with the Nurse #2, it was confirmed that the facility failed to maintain an accurate and up-to-date Individual Resident Control Drug Medication Observation Record, as documented by the facility. 12. During an interview conducted at approximately 3:00 PM, the Administrator acknowledged the findings. Mandated Correction Date: 7/18/07. 13. During the revisit survey conducted on 8/09/07 and based on record review and interview, the facility failed to maintain an accurate and up-to-date Medication Observation Record for 4 out of 13 sampled residents (Resident #'s 3, 7, 8 and 12). 14. During an interview with the Director of Nursing (DON) on 08/09/07 at approximately 12:00 PM, it was reported that Resident #'s 3, 7, 8 and 12 all require and receive assistance with self-administered medications by facility staff. Upon the medication review during the complaint investigation survey, it was revealed that the facility failed to ensure that Resident #'s 3, 7, 8 and 12, received medications as ordered on a regular basis, as follows: 15 During a review of Resident #3's Medication Observation Record (MOR) dated 07/07, it was revealed that the resident was prescribed the following medication:. Fosamax 70 mg, 1 tablet once per week. However, during a further review of the MOR, it was noted that the MOR documented that the resident consumed this medication on 07/04/07 and twice during the second week of July 2007, specifically on 07/07/07 and 07/09/07. The MOR lacked documentation (i.e. staff initials) indicating that the resident received assistance with this medication during the remaining portion of July 2007. Further record review and interview with the DON revealed that the facility did not have documentation indicating that the resident's physician was notified of the aforementioned medication discrepancies including the double dosage of the medication that was given during the week of 07/06/07-07/12/07 and the missed dosages during the remaining portion of the month from 07/13/07 to 07/31/07, as previously mentioned. 16. During a review of Resident #7's Medication Observation Record (MOR). dated 06/2007, 07/2007 and 08/2007, it was revealed that the resident was prescribed the following medication: Albuterol Inhaler Kit 17 GM, Inhale 4 puffs 4 times daily. Upon interview with the DON during the medication review, it was reported that the facility allows the resident to self-administer the medication and keep this medication in his/her possession, at all times. However, during a further review of Resident #7's MOR's, it was noted that the MOR's documented (i.e. staff initials) that the resident received assistance from facility staff with the Albuterol Inhaler 4 times daily from 06/01/07 to 06/30/07, 07/01/07 to 07/31/07 and several times daily from 08/01/07 to 08/08/07. During a further interview, the DON reported that the facility did not have orders from the resident's physician permitting the resident to self-administer the medication. Further interview and record review revealed that the facility could not assure that the resident appropriately self-administered and consumed the medication, as prescribed by his/her physician. 17.. During a review of Resident #8's Medication Observation Record (MOR) dated 07/2007 and 08/2007, it was revealed that the resident was prescribed the following medication: Advair 250/50 #60, Inhale 1 puff twice daily. Upon interview with the DON, during the medication review, it was reported that the facility allows the resident to self-administer the medication and keep this medication in his/her possession, at all times. However, during a further review of Resident #8's MOR's, it was noted that the MOR's documented that the resident received assistance from facility staff with the Advair Inhaler twice daily from 07/01/07 to 07/31/07 and once to twice daily from 08/01/07 to 08/09/07. During a further interview, the DON reported that the facility did not have orders from the resident's physician permitting the resident to self-administer the medication. Further interview and record review revealed that the facility could not assure that the resident appropriately self-administered and consumed the medication, as prescribed by his/her physician. a) During a further review of Resident #8's MOR's dated 07/2007 and 08/2007, it was revealed that the resident was prescribed the following additional medications: b) Albuterol Sulfate .83/ML, use 1 vial via nebulizer 3 times daily; and c). Ipratropium 0.02% Nebulizer Solution, use 1 vial via nebulier three times daily. 18. During a further interview with the DON, it was reported that Resident #8 is currently receiving assistance with the two aforementioned medications through a home health agency. However, during a further interview with the DON and review of Resident #8's MOR's (07/2007 and 08/2007), it was revealed that the facility staff documented (i.e. staff member initials), indicating that the resident received assistance from facility staff member with the two aforementioned medications from 07/01/07 to 07/31/07 and from 08/01/07 to 08/09/07. 19. During a further review of Resident #8's MOR dated 08/2007, it was revealed that the resident was prescribed the following medications: Zinc Sulfate 200 mg, 1 tablet once daily and Vitamin C 500 mg, 1 tablet once daily. Further review of the MOR revealed that there was no documentation (i.e. staff member initials), indicating that the resident received assistance with this medication nor was there documentation explaining the missed deses of the aforementioned medications from 08/01/07 to 08/09/07. 20. During a review of Resident #12's Medication Observation Record (MOR) dated 07/2007 and 08/2007, it was revealed that the resident was prescribed that following medication: Albuterol Inhalation Kit 17 grams, Inhale 1 puff every 6 hours. Upon interview with the DON during the medication review, it was reported that the facility allows the resident to self-administer the medication and keep this medication in his/her possession, at all times. However, during a further review of Resident #12's MOR's, it was noted that the MOR's documented that the resident received assistance from facility staff with the Albuterol Inhaler up to four times daily from 07/01/07 to 07/23/07. During a review the resident's MOR dated 08/2007, there was no documentation indicating that the resident received assistance with this medication from 08/01/07 to 08/09/07. During a further interview, the DON reported that the facility did not have orders from the resident's physician permitting the resident to self-administer the medication. Further interview and record review revealed that the facility could not assure that the resident appropriately self- administered and consumed the medication, as prescribed by his/her physician. 21. During a further interview conducted at approximately 3:00 PM, the DON confirmed the aforementioned discrepancies. This is an uncorrected deficiency from 6/19/07. The new correction date given: 9/08/07. _ 22, During the second revisit survey conducted on 10/02/07 and Based on record review and interview, the facility failed to maintain an accurate and up-to-date Medication Observation Record (MOR) for 8 out of 13 sampled residents (Resident #'s 1, 2, 3, 4, 6, 8, 11 and 12). 23. During an interview with Medication Technician #1 on 10/02/07 at approximately 1:00 PM, it was reported that Resident #'s 1, 2, 3, 4, 6, 8, 11 and 12 all require and receive assistance with self-administered medications by facility staff. Upon the medication review, accompanied by the Director of Nursing (DON), on 10/02/07 at approximately 1:50 PM, it was revealed that the facility failed to ensure that Resident #'s 1, 2, 3, 4, 6, 8, 11 and 12, received medications as ordered on a regular basis, as follows: 24. During a review of Resident #1's Medication Observation Record (MOR) dated 10/07, it was revealed that the resident was prescribed the following medications: a. Hydralazine 50 mg, take 1 tablet three times daily. b. Carbamazepin 200 mg, take 1 tablet three times daily. 25. During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused these medications on 10/02/07 at 12 PM. 26. During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 12 PM, as ordered by his/her physician. 27. During a review of Resident #2's Medication Observation Record (MOR) dated 10/07, it was revealed that the resident was prescribed the following medication: a. Oxycodo-APAP 10-325, take 1 tablet every 6 hours, as needed for pain. 28. During a further review of the MOR, it was revealed that the resident. was assisted with this self-administered medication on 10/01/07 at 5:00 PM. Further review of the MOR revealed that the facility staff assisted the resident with a second dose of this medication on 10/01/07. However, there was no documentation by facility staff indicating the exact time that the 2nd dose was given to ensure that sufficient time had lapsed between the time that the ist dose and 2nd dose was given to the resident, as prescribed by his/her physician. 29. During a review of Resident #3's Medication Observation Record (MOR) dated 10/07, it was revealed that the resident was prescribed the following medication: a. Lexapro 20 mg, take one tablet every morning. 30. During a further review, it was revealed that the MOR lacked documentation indicating that the resident received “U assistance, and/or was offered, and/or refused these medications for two consecutive days including 10/01/07 and 10/02/07 at 8 AM. During a further interview with the DON and Medication Technician #1, 4it was confirmed that the resident did not receive the aforementioned medication on 10/01/07 and 10/02/07.at 8 AM, as ordered by his/her physician. 31. During a review of Resident #4's Medication Observation Record (MOR) dated 10/2007, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the following medications on 10/02/07 at the designated times, as follows: a. Omeprazole 20 mg, take 1/2 tablet once daily (8 AM) b. Thera-M tabs, take one tablet once daily (8 AM) c. Thiamine HCL 100 mg, take one tablet once daily (8 d. Folic Acid 1 mg, take 1/2 tablet once daily (8 AM) e. Calcium Carb, take 1 tablet twice daily (8 AM) f£. Tramadol HCL 50 mg, take 1 tablet three times daily (8 AM and 12 PM) g. Campral 333 mg, take 1 tablet three times daily (8 AM and 12 PM) 32. During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 8 AM and/or 12 PM, as ordered by his/her physician. 33. During a further review of Resident #4's MOR, the following discrepancies were revealed as follows: a. The MOR read: Folic Acid 1 mg, take 1/2 tablet once daily. However, the label read: take 1 tablet once daily. b. The MOR read: Tramadol HCL 50 mg, take two tablets three times daily. However, the label read: take two tablets three times daily, as needed for lower back and hip pain. 34. During a review of Resident #6's Medication Observation Record (MOR) dated 10/2007, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the following medications, on 10/02/07 at 8 AM, as ordered by his/her physician, as follows: a. Fluoxetine 10 mg, take 1 capsule daily. b. Asprin 325 mg, take 1 tablet daily. c. Toprol XL 100 mg, take 1 tablet daily. d. Triamt/HCTZ 37.5 mg, take 1 tablet in the morning. 35. During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 8 AM, as ordered by his/her physician. 36. During a review of Resident #8's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medications: a Fluoxetine 20 mg, take 1 capsule daily. b. Citalopram 20 mg, take 1 capsule daily. 37. During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medications for two consecutive days including 10/01/07 and 10/02/07 at 8 AM. 38. Further review of the MOR revealed that the resident was prescribed the following additional medications: c. Hydroxyz HCL 25 mg, take 1 capsule daily. d. Geodon 40 mg, take 1 capsule daily. e. Amlodipine 10 mg, take 1 tablet daily. 39. During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medications on 10/02/07 at 8 AM. 40. During a further interview with the DON, it was confirmed that the resident did not receive the aforementioned medication on 10/01/07 and 10/02/07 at 8 AM, as ordered by his/her physician. 41. During a review of Resident #11's Medication Observation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medications: a. Ferrous Sulfate 325 mg, take 1 tablet three times daily. b. Gabapentin 300 mg, take 2 tablets three times daily. 42. During a further review, it was revealed that the MOR lacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medications on 10/02/07 at 12 PM. 43. During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 12 PM, as ordered by his/her physician. 44. During a further review of Resident #11's MOR, the following discrepancies were revealed as follows: a. The MOR read: Gabapentin 300 mg, take 2 capsules 3 times daily. However, the label read: take 1 tablet three times daily. 45. During a review of Resident #12's Medication Cbservation Record (MOR) dated 10/2007, it was revealed that the resident was prescribed the following medication: a. Norvasc 10 mg, take 1 capsule once daily. 46. During a further review, it was revealed that the MOR dacked documentation indicating that the resident received assistance, and/or was offered, and/or refused the aforementioned medication on 10/02/07 at 8 AM. 47. During a further interview with the DON and Medication Technician #1, it was confirmed that the resident did not receive the aforementioned medications on 10/02/07 at 12 PM, as ordered by his/her physician. 48. During an interview with the Administrator at approximately 3:00 PM, the findings were acknowledged. 49. Based on the foregoing, Palm Beach Assisted Living Facility violated Rule 58A-5.0185(5)(b), Florida Administrative Code, An uncorrected Class III deficiency, which carries, in this case, an assessed fine of $12,000.00 ($500.00 X 24 days from 9/09/07 through 10/02/07 from the follow-up visit to the second revisit). 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 Count I. B. Assess an administrative fine of $12,000.00 against Palm Beach Assisted Living Facility on Count I pursuant to Section 429.19, Florida Statutes. c. 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 16 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. fa 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 A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, REPRESENTED BY AN ATTORNEY IN THIS OU & THE RIGHT TO B ria LawtoOn-Russell Assistant General Counsel Agency for Health Care Administration 8350 N. W. Suite Miami, Copies furnished to: Field Office Manager Agency for Health Care Administration 5050 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (Inter-office 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) 103 52™¢ Terrace Florida 33166 Leni 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 Roy E. Glucksman, Administrator, Palm Beach Assisted Living Facility, 534 Datura Street, West Palm Beach, Florida 3340land to Joseph Glucksman, Registered Agent, 534 tura Street, laite #200, Wet ach, Florida 33401 on //Palm , 2007. Fok #497 BV IFFS SENDER: COMPLETE THIS. SECTION COMPLETE THIS SECTION ON DELIVERY ™ Complete items 1, 2, and 3. Also corplete * item 4 if Restricted Delivery is desired. "al Print your name and address on the reverse ” so that we can returri the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. Cc. Date of Deliyery S hax/ed D. Is delivery address different from item 1? [I Yes If YES, enter delivery address below: [1 No 1. Article Addressed to: . Service Type Certified Mail (1 Express Mail CD Registered Return Receipt for Merchandise Ci Insured Mail =. C.0.D. 4. Restricted Delivery? (Extra Fee) 2. Article Number (Transfer from service label) 7004 2890 O000 5525 9310 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-154¢ 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: . =. th COMPLETE THIS SECTION ON DELIVERY hal ON D. Js delivery address different from item 1? 1 Yes If YES, enter delivery address below: No 3. ores Type Certified Mail (1 Express Mail C1 Registered EX Return Receipt for Merchandise 0 Insured Mail €)c.0.D. 4, Restricted Delivery? (Extra Fee) 2, Article Number (Transfer trom service fa 7004 2890 0000 5525 4303 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 08-005154