O¥-SY(D %p, oY STATE OF FLORIDA > a } 2 oe Ss AGENCY FOR HEALTH CARE ADMINISTRATION OL), by & Ue, WGA , STATE OF FLORIDA AGENCY FOR EB oe, HEALTH CARE ADMINISTRATION, Wy e SF den Petitioner, Case Nos. 2008010733 vs. 2008010608 KIPLING MANOR RETIREMENT CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against KIPLING MANOR RETIREMENT CENTER, (hereinafter “Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes, (2007), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an assisted living facility and impose an administrative fine in the sum of thirty-seven thousand dollars ($37,000.00) based upon five (5) State Class I deficiencies (Counts I, II, If], VI, VID), two (2) State Class I deficiencies (Count IV, VIII), one State Class II deficiency (Count IX), one State Class II deficiency (Count V), and in addition an action to impose an survey fee in the sum of five hundred dollars ($500.00) pursuant to §429.275. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Florida Statutes (2007). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES | 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 4. Respondent operates a sixty five (65)-bed assisted living facility located at 7901 Kipling Street, Pensacola, Florida 32514, and is licensed as an assisted living facility, under license number 7285. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I Respondent’s administrator failed to ensure adequate care to all residents as evidenced by failing to provide assistance with self administration of medications and had unlicensed staff administer medications (A610); facility failed to have a licensed nurse administer medications and facility failed to administer psychiatric medications in accordance with the physician orders (A613); facility failed to maintain an accurate medication observation record (A615); facility failed to store medications in a locked cart out of reach of wandering and confused residents on the specialty unit (A619); facility failed to ensure that prescriptions were filled in a timely manner (A631); facility failed to notify family, physician, or responsible party of resident changes in condition (A706); facility failed to serve diets as ordered by the physician, failed to follow the menu, and failed to have therapeutic meals listed on menus (A806). 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 8. Based on observation, interview and record review, Respondent’s administrator failed to ensure adequate care to all residents as evidenced by facility failing to provide assistance with self administration of medications and had unlicensed staff administer medications (A610); facility failed to have a licensed nurse administer medications and facility failed to administer psychiatric medications in accordance with the physician orders (A613); facility failed to maintain an accurate medication observation record (A615); facility failed to store medications in a locked cart out of reach of wandering and confused residents on the specialty unit (A619); facility failed to ensure that prescriptions were filled in a timely manner (A631); facility failed to notify family, physician, or responsible party of resident changes in condition (A706); facility failed to serve diets as ordered by the physician, failed to follow the menu, and failed to have therapeutic meals listed on menus(A806), the same being in violation of law. 9. That the failure of Respondent’s administrator to ensure adequate care to all residents as evidenced by the facility failing to provide assistance with self administration of medications and having unlicensed staff administer medications (A610); facility failed to have a licensed nurse | administer medications and facility failed to administer psychiatric medications in accordance with the physician orders (A613); facility failed to maintain an accurate medication observation record (A615); facility failed to store medications in a locked cart out of reach of wandering and confused residents on the specialty unit (A619); facility failed to ensure that prescriptions were filled in a timely manner (A631); facility failed to notify family, physician, or responsible party of resident changes in condition (A706); facility failed to serve diets as ordered by the physician, failed to follow the menu, and failed to have therapeutic meals listed on menus (A806), the same being in violation of law. 10. That the Agency determined that this deficient practice presented an imminent danger to the residents and serious physical or emotional harm would result and cited Respondent for a State Class I deficiency. 11. The regulatory provisions of the Fla. Admin. Code (2007) that are pertinent to this alleged violation read as follows: 58A-5.019 (1) Staffing Standards. ADMINISTRATORS. Every facility shall be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents as required by Part I of Chapter 429, F.S., and this rule chapter. * OK OK WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to 58A- 5.019(1) Fla. Admin. Code (2007). COUNT II Respondent failed to provide assistance with self administration, and had unlicensed staff administer medications to 4 of 4 residents (#1, 2, 8, 9) during medication pass observation. Medication pass observation was observed on all units (2 of 2) and 2 medication technicians (med techs) were observed. 12. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 13. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 14. That based on observation, staff interview, and record review, the Respondent has failed to provide assistance with self administration, and had unlicensed staff administer medications to 4 of 4 residents (#1, 2, 8, 9) during medication pass observation. Medication pass observation 4 was observed on all units (2 of 2) and 2 medication technicians (med techs) were observed, the same being in violation of law. The findings include: a. Observation of medication pass on the special care unit on 9/3/08 at 8:40 AM revealed a med tech standing at the medication cart (alone) placing medications in a cup for resident #2: Roxanol (narcotic analgesic) 5 mg, Glipizide (antidiabetic agent) 5 mg , Lasix (diuretic) 20 mg, Zoloft (antidepressant) 100 mg, K+ 10 meq (potassium), Risperdal (antipsychotic agent) 0.5 mg, Trilisate (arthritis) 500 mg, Tylenol (analgesic) 500 mg, Valium (anxiety disorders) 2 mg. The medications were placed in a medication cup and crushed except Roxanol was added to 8 ounces of orange juice (OJ). The medications were taken to the resident at the breakfast table in the common dining room. . The med tech did not take the medication, in its dispensed, properly labeled container, from where it was stored and bring it to the resident. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. The med tech poured the crushed medications on the top of the resident’s pancakes and placed the OJ with the Roxanol at the residents place. The med tech stated she has to feed the resident and this is the only way they can get the resident to take the medication.. The med tech was busy with other things and left the resident sitting at the dining room table with the crushed medications on top of the pancakes and the OJ with the Roxanol on the table. There were two other residents sitting at the dining room table with resident #2 at this time. Both residents were confused and wandered. These three residents were not supervised or observed by the medication tech. Resident #2 ate half of the food and drank half of the OJ. Resident #2 did not receive Natural Tears one gtt (drop) in both eyes as ordered. The med tech stated the medication was not available from the pharmacy. . Observation of medication pass on the special care unit on 9/3/08 at 8:15 AM revealed a med tech aide standing at the medication cart alone placing the following medications for resident #1 in a medication cup: Cogentin (antiparkinson's disease) one 20 milligrams (mg) and one Mestinon (myasthenia gravis) 60 mg. The medications were placed in a medication cup at the cart then taken in the cup to the resident, The medication was poured on to the bed and the resident picked the medication up and took the medication. The med tech did not, take the medication, in its dispensed, properly labeled container, from where it was stored and bring it to the resident. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. Observation of medication pass in the main building on 9/3/08 at 8:55 AM 5 15. revealed a med tech standing at the medication cart placing the following medications for resident #8 into a medicine cup: Norvasc (high blood pressure) 5 mg, Seroquel (schizophrenia, bipolar disorder) 400 mg, Lopressor (high blood pressure) 50 mg, Depakote (seizures, bipolar disorder) 500 mg, Haldol (schizophrenia) 5 mg, Tegretol (seizures, bipolar disorder) 20 mg, and Klonopin (seizures, panic disorder) 1 mg. The medications were placed in a medication cup at the cart and the cup of medications was given to the resident. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. Observation of medication pass in the main building on 9/3/08 at 8:55 AM revealed a med tech standing at the medication cart placing the following medications for resident #9 in a medication cup: Glipizide (antidiabetic agent) 5 mg, Vesicare (overactive bladder) 5 mg, Actophusmet 15-500, Lopid (high cholesterol) 600 mg, Haldol (schizophrenia) 5 mg, Iron 325 mg, Seroquel (schizophrenia, bipolar disorder) 300 mg, Phenobarbital (sedative, seizures) 64.8, and Depakote (seizures, bipolar disorder) 500 mg. The medications were placed in a cup at the cart and handed to the resident who was next to the cart. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. . On 9/4/08 at 3:10 PM the administrator, assistant administrator, and director of nursing were made aware of the observations. That the failure to provide assistance with self administration, and having unlicensed staff administer medications to 4 of 4 residents (#1, 2, 8, 9) during the medication pass observation, is in violation of law. 16. That the Agency determined that this deficient practice presented an imminent danger to the residents and serious physical or emotional harm would result and cited Respondent for a State Class I deficiency. 17. The regulatory provisions of the Fla. Admin. Code (2007) that are pertinent to this alleged violation read as follows: 429,.256(3)(a) and (b) Assistance with self-administration of medication (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident. (b) In the presence of the resident, reading the label, opening the container, removing a prescribed amount of medication from the container, and closing the container. 6 OK WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to 58A- 5.0185 (3)(c) Fla. Admin. Code (2007). COUNT III Respondent failed to have a licensed nurse administer medications to 4 of 4 residents (#1, 2, 8, 9) during medication pass observation. Medication pass observation was observed on all units (2 of 2) and 2 medication technicians (med techs) were observed; and facility failed to administer psychiatric medications in accordance with the physician order for 1 resident, #12, who had to be admitted to a crisis stabilization unit for care. 18. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 20. That based on observations, staff interview, and record review the facility failed to have a licensed nurse administer medications to 4 of 4 residents (#1, 2, 8, 9) during medication pass observation. Medication pass observation was observed on all units (2 of 2) and 2 medication technicians (med techs) were observed; and facility failed to administer psychiatric medications in accordance with the physician order for 1 resident, #12, who had to be admitted to a crisis stabilization unit for care, the same being in violation of law. The findings include: a. Observation of medication pass on the special care unit on 9/3/08 at 8:40 AM revealed a med tech standing at the medication cart (alone) placing medications in a cup for resident #2: Roxanol (narcotic analgesic) 5 mg, Glipizide (antidiabetic agent) 5 mg , Lasix (diuretic) 20 mg, Zoloft (antidepressant) 100 mg, K+ 10 meq (potassium), Risperdal (antipsychotic agent) 0.5 mg, Trilisate (arthritis) 500 mg, Tylenol (analgesic) 500 mg, Valium (anxiety disorders) 2 mg. The medications were placed in a 7 medication cup and crushed except Roxanol was added to 8 ounces of orange juice (OJ). The medications were taken to the resident at the breakfast table in the common dining room. : . The med tech did not, take the medication, in its dispensed, properly labeled container, from where it was stored and bring it to the resident. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. . The med tech poured the crushed medications on the top of the resident’s pancakes and placed the OJ with the Roxanol at the residents place. The med tech stated she has to feed the resident and this is the only way they can get the resident to take the medication. The med tech was busy with other things and left the resident sitting at the dining room table with the crushed medications on top of the pancakes and the OJ with the Roxanol on the table. There were two other residents sitting at the dining room table with resident #2 at this time. Both residents were confused and wandered. These three residents were not supervised or observed by the medication tech. Resident #2 ate half of the food and drank half of the OJ. Resident #2 did not receive Natural Tears one gtt (drop) in both eyes as ordered. The med tech stated the medication was not available from the pharmacy. . Observation of medication pass on the special care unit on 9/3/08 at 8:15 AM revealed a med tech aide standing at the medication cart alone placing the following medications for resident #1 in a medication cup: Cogentin (antiparkinson's disease) one 20 milligrams (mg) and one Mestinon (myasthenia gravis) 60 mg. The medications were placed in a medication cup at the cart then taken in the cup to the resident. The medication was poured on to the bed and the resident picked the medication up and took the medication. The med tech did not, take the medication, in its dispensed, properly labeled container, from where it was stored and bring it to the resident. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. Observation of medication pass in the main building on 9/3/08 at 8:55 AM revealed a med tech standing at the medication cart placing the following medications for resident #8 into a medicine cup: Norvasc (high blood pressure) 5 mg, Seroquel (schizophrenia, bipolar disorder) 400 mg, Lopressor (high blood pressure) 50 mg, Depakote (seizures, bipolar disorder) 500 mg, Haldol (schizophrenia) 5 mg, Tegretol (seizures, bipolar disorder) 20 mg, and Klonopin (seizures, panic disorder) 1 mg. The medications were placed in a medication cup at the cart and the cup of medications was given to the resident. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. 21. Observation of medication pass in the main building on 9/3/08 at 8:55 AM revealed a med tech standing at the medication cart placing the following medications for resident #9 in a medication cup: Glipizide (antidiabetic agent) 5 mg, Vesicare (overactive bladder) 5 mg, Actophusmet 15-500, Lopid (high cholesterol) 600 mg, Haldol (schizophrenia) 5 mg, Iron 325 mg, Seroquel (schizophrenia, bipolar disorder) 300 mg, Phenobarbital (sedative, seizures) 64.8, and Depakote (seizures, bipolar disorder) 500 mg. The medications were placed in a cup at the cart and handed to the resident who was next to the cart. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. . On 9/4/08 at 3:10 PM the administrator, assistant administrator, and director of nursing were made aware of the observations. Record review of “chart notes “revealed resident #12 was admitted 8/29/08 at-1:00 p.m. . Record review of the Department of Elder Affairs/Assisted Living Facility Form 1823 health assessment for resident #12 dated 8/27/08 indicated a diagnosis of schizoaffective disorder bipolar type, organic affective disorder with confusion and psychosis. Medications ordered on the health assessment included: Risperdal (schizophrenia, bipolar disorder) 3 milligrams twice daily, Cogentin (antiparkinson's disease) 1 milligram (mg) two times a day as needed, Haldol (schizophrenia) 5 milligrams every 6 hours as needed, Ativan (anxiety) 2 milligrams every 6 hours as needed, Klonopin (seizures, panic disorder) 0.5 milligrams two times day, and Klonopin 0.5 milligrams, 2, at HS (bedtime). In addition, Haldol and Ativan had lines drawn through them and the notation “D/C‘d 8/29/08 “. Review of the MOR indicated: Risperdal 3 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Risperdal 3 mg given only once on 9/1/08 with no time documented. Should have been given twice daily. Cogentin 1 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Haldol 5 mg given 9/1/08 at 8:00 a.m. and 9/2/08 at 9/2/08 with no documented reason or response. This was after the discontinuation date of 8/29/08. Ativan “four Ativan to equal 2 mg” given 9/1/08 at 1:00 p.m. “c/o anxiety “with no response documented. This was after the discontinuation date of 8/29/08. Ranitidine 50 mg. was given 9/1/08 once with no time documented. There was no physician order for this medication. The Klonopin was not administered as it was not on the MOR to be given. On 9/2/08 at 10:00 a.m. the resident exhibited erratic behavior, saw sparks coming out of the light sockets, room was in disarray, wandered in/out of other residents ' rooms and went through their belongings. Resident had to be admitted to a crisis stabilization unit for care and treatment. The failure to have a licensed nurse administer medications to 4 of 4 residents (#1, 2, 8, 9 9) during medication pass; and the failure to administer psychiatric medications in accordance with the physician order for 1 resident, #12, who had to be admitted to a crisis stabilization unit for care, reflects the Respondent’s failure to provide physician prescribed medications the same being in violation of law. 22. That the Agency determined that this deficient practice presented an imminent danger to the residents and serious physical or emotional harm would result and cited Respondent for a State Class I deficiency | 23. The regulatory provisions of the Fla. Admin. Code and Florida Statues (2007) that is pertinent to this alleged violation read as follows: 58A-5.0185 (4)(a) Medication Practices. MEDICATION ADMINISTRATION. (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.” * OOK WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 58A 5.0185 (4)(a) Florida Admin. Code. COUNT IV The Respondent failed to maintain an accurate medication observation record (MOR) for 1 (#12) of 22 sampled residents, who had to be admitted to a crisis stabilization unit for care and services. 24, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 25. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 26. That based on record review and staff interview the facility failed to maintain an accurate medication observation record (MOR) for 1 (#12) of 22 sampled residents, who had to be admitted to a crisis stabilization unit for care and services, the same being in violation of law. The findings include: a. Record review of “chart notes" revealed resident was admitted 8/29/08 at 1:00 p.m. Record review of the Department of Elder Affairs/Assisted Living Facility Form 1823 health assessment for resident #12 dated 8/27/08 indicated a diagnosis of schizoaffective disorder bipolar type, organic affective disorder with confusion and psychosis. Medications ordered on the health assessment included: Risperdal (schizophrenia, bipolar disorder) 3 milligrams twice daily, Cogentin (antiparkinson's disease) 1 milligram (mg) two times a day as needed, Haldol (schizophrenia) 5 milligrams every 6 hours as needed, Ativan (anxiety) 2 milligrams every 6 hours as needed, Klonopin (seizures, panic disorder) 0.5 milligrams two times day, and Klonopin 0.5 milligrams, 2, at HS (bedtime). In addition, Haldol and Ativan had lines drawn through them and the notation “D/C‘d 8/29/08 “. b. Review of the MOR indicated: Risperdal 3 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Risperdal 3 mg given only once on 9/1/08 with no time documented. Should have been given twice daily. Cogentin 1 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Haldol 5 mg given 9/1/08 at 8:00 a.m. and 9/2/08 at 9/2/08 with no documented reason or response. This was after the discontinuation date of 8/29/08. Ativan “four Ativan to equal 2 mg” given 9/1/08 at 1:00 p.m. “c/o anxiety “with no response documented. This was after the discontinuation date of 8/29/08. Ranitidine 50 mg. was given 9/1/08 once with no time documented. There was no physician order for this medication. The Klonopin was not administered as it was not on the MOR to be given. c. On 9/2/08 at 10:00 a.m. the resident exhibited erratic behavior, saw sparks coming out of the light sockets, room was in disarray, wandered in/out of other residents ' rooms and went through their belongings. Resident had to be admitted to a crisis stabilization unit for care and treatment. 27. The failure to maintain an accurate medication observation record (MOR) for 1 (#12) of 22 sampled residents, who had to be admitted to a crisis stabilization.unit for care and services, reflects the Respondent’s failure to maintain an accurate daily medication observation record, the same being in violation of law. 28. That the Agency determined that this deficient practice presented an imminent danger to the residents and serious physical or emotional harm would result and cited Respondent for a i State Class I deficiency. 29. The regulatory provisions of the Fla. Admin. Code and Florida Statues (2007) that is pertinent to this alleged violation read as follows: 58A-5.0185 (5)(c) Medication Practices. MEDICATION RECORDS. 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. OOF WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 58A-5.0185 (5)(c) Florida Admin. Code. COUNTY Respondent failed to store medications in a locked cart out of reach of wandering and confused residents on the specialty unit, which has the potential for harm. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 30. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 31. Based on observation the facility failed to store medications in a locked cart out of reach of wandering and confused residents on the specialty unit which has the potential for harm, the same being in violation of law. The findings include: a. Observation of medication pass on the special care unit on 9/3/08 at 8:40 AM revealed a med tech standing at the medication cart (alone) placing medications in a cup for resident #2: Roxanol (narcotic analgesic) 5 mg, Glipizide (antidiabetic agent) 5 mg , Lasix (diuretic) 20 mg, Zoloft (antidepressant) 100 mg, K+ 10 meq (potassium), Risperdal (antipsychotic 12 agent) 0.5 mg, Trilisate (arthritis) 500 mg, Tylenol (analgesic) 500 mg, Valium (anxiety disorders) 2 mg. The medications were placed in a medication cup and crushed except Roxanol was added to 8 ounces of orange juice (OJ). The medications were taken to the resident at the breakfast table in the common dining room. The med tech did not, in the presence of the resident, read the label, open the container, remove the prescribed amount of medication from the container, and close the container. b. The med tech poured the crushed medications on the top of the resident’s pancakes and placed the OJ with the Roxanol at the residents place, The med tech stated she has to feed the resident and this is the only way they can get the resident to take the medication. The med tech was busy with other things and left the resident sitting at the dining room table with the crushed medications on top of the pancakes and the OJ with the Roxanol on the table. There were two other residents sitting at the dining room table with resident #2 at this time. Both residents were confused and wandered. These three residents were not supervised or observed by the medication tech. Resident #2 ate half of the food and drank half of the OJ. Resident #2 did not receive Natural Tears one gtt (drop) in both eyes. The med tech stated the medication was not available from the pharmacy. c. Observation on 9/3/08 at 8:15 AM on the specialty care unit the following medications were noted on top of an unattended medication cart, out of view of the med tech: Namenda (dementia) 10 mg and Lisinopril (high blood pressure) 5 mg and Aricept (dementia) 10 mg. The med tech went out the back door on two occasions leaving the medications on top of the cart with confused/wandering residents present. 32. That the failure to store medications in a locked cart out of reach of wandering and confused residents on the specialty unit which has the potential for harm, the same being in violation of law. 33. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 34. The regulatory provisions of the Fla. Admin. Code (2007) that is pertinent to this alleged violation read as follows: 58A-5.0185 (6)(b) Medication Practices. MEDICATION STORAGE AND DISPOSAL. Centrally stored medications must be: 1. Kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area 13 at all times; 2. Located in an area free of dampness and abnormal temperature, except that a medication requiring refrigeration shall be refrigerated. Refrigerated medications shall be secured by being kept in a locked container within the refrigerator, by keeping the refrigerator locked, or by keeping the area in which refrigerator is located locked; 3. Accessible to staff responsible for filling pill-organizers, assisting with self-administration, or administering medication. Such staff must have ready access to keys to the medication storage areas at all times; and 4. Kept separately from the medications of other residents and properly closed or sealed. * OK OK WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 58A-5.0185 (6)(b), Florida Admin. Code. COUNT VI Respondent failed to ensure that prescriptions for 14 (#1, 2, 3, 4, 5, 7, 10, 11,12, 13, 14, 15, 16, 17) of 22 residents were filled in a timely, manner which jeopardized the health of residents #3, #4 and #12. 35. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 37. That based on resident record review, family interviews, and an interview with staff and the owner, the facility failed to ensure that prescriptions for 14 (#1, 2, 3, 4, 5, 7, 10, 11, 12, 13, 14, 15, 16, 17) of 22 residents were filled in a timely manner, which jeopardized the health of residents #3, #4 and #12, the same being in violation of law. The findings include: a. Review of resident #3 's Department of Elder Affairs/Assisted Living Facility (DOEA/ALF) Form 1823 health assessment (no date) indicated a diagnosis of chest pain and shortness of breath and assistance with activities of daily living. A second health assessment dated 1/12/07 indicated diagnoses of chronic obstructive pulmonary disease, smoker, coronary artery disease with atrial fibulation, anxiety, agitation, dementia. This assessment included a 14 mo physician order for Nitroglycerin (angina pectoris) 0.3 milligrams (mg.) patch on at 0600 and off at 2200. Hospice progress notes dated 8/28/08 indicate diagnosis of debility. Review of medication observation record (MOR) indicated the following: May 2008 indicated the resident to receive Nitro-Dur 0.3 mg every morning and remove every evening. The following dates indicate initials that are circled: May 1, May 2, May 3, May 4, May 5, May 6, and 7/08. Interview with staff on 9/3/08 at 10:00 AM stated we circle our initials when the resident refuses or the medication was not given and document why on the back of the MOR. Review of the back of the May 2008 MOR revealed staff notation for 5/1-7/08 stating Nitro-patch on order. Another MOR dated May 2008 indicated Nitro-patch ON at 8:00 a.m. was circled (not given) May 8, 9, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25 and on the back of the MOR it was documented for 5/5, 5/8, 5/9, 5/10 on order/not available. June 2008 indicated Nitro-patch circled on June 26, 27, 28, 29, 30 and on the back documented not available for 6/26, 6/27, 6/28, 6/29, 6/30. Protonix (erosive esophagitis associated with gastro-esophageal reflux disorder) was circled as not given on June 27, 28, 29, blank on 30 and.31; and on the back documented on order 6/28/08, 6/29/08, and 6/31/08. July 2008 indicated Nitro-patch was circled as not given July 1, 2, 3, 4, 5, 6, and on the back documented not available July 1,2,3,5,6,7,8,9,10, and 11. August 2008 indicated Nitro-patch not available for the following dates: August 12 and 14. Lexapro (major depressive disorder) 10 mg was not available on 8/5/08. Amaryl (diabetes) 1 mg was not available August 2 and 3. Ultram (analgesic) 50 mg not available August 2-3. Review of Hospice progress notes from 8/13/08-8/25/08 indicate resident had wheezing and rhonchi, no pain, good appetite; gets up and out to smoke and eat meals, denies pain, edema in feet/ankles continues up to 2+ at times, rhonchi; dated 8/25/08 indicated resident continues to have irregular pulse with lower extremity pitting edema 2 + at feet with 1+ at mid shins. Has respiratory wheezing and rhonchi, refuses respiratory treatment or oxygen. Resident becomes short of breath with ambulation of 40 feet. Mental status prevents resident from comprehending results of non-compliance with treatment orders. Interview with administrator 9/4/08 2:10 PM stated the resident went to the emergency room on 8/30/08. She stated she was on call for the facility and received a call stating the resident was short of breath, B/P 160/110 and face very red. Review of the record including the chart notes lacked documentation that the missed medications listed above were called to the family and or physician. The record also lacked documentation about the resident becoming ill 8/30/08 and being admitted to the hospital. The resident was still in the hospital as of 9/5/08. Review of resident #4 's DOEA/ALF Form 1823 health assessment dated 1/10/08 indicated a diagnosis of schizoaffective disorder depressive type. Record review of MORs indicated the following: May 2008 an order for Vistaril (anxiety) 25 mg for anxiety as needed ordered 1/08. Vistaril was given for anxiety 18 times in the month of May 2008. June 2008 the resident 15S received Vistaril 15 times. Review of the MOR's prior to May 2008 revealed the resident did not require that many doses of anti-anxiety medications. . Review of the chart notes dated 7/13/08 indicated the resident cut her wrist with a razor, sprayed self with hairspray and threatened to set self on fire. Resident was transported to hospital and was admitted to a psychiatric unit. The resident returned to the assisted living facility on 7/17/08. . August 2008 MOR indicated Effexor (major depressive disorder, general anxiety disorder, social anxiety) was not available/on order August 1-21 and August 24-26. . The September 2008 MOR indicated Effexor not given 9/1/08, not available. . Other medications that were not available as indicated on the MOR's include: Lescol for high cholesterol not given 8/1-11/08 with notation written on MOR stating authorization required. Protonix (erosive esophagitis associated with gastro-esophageal reflux disorder) 40 mg one a day was not given 8/5-31/08, 9/1 and 2/08 with notation on back of MOR stating prior authorization needed. On 9/1/08 notation written on MOR stating order change. Reglan (gastro-esophageal reflux disorder) 5 mg three times a day was not given 2 times 9/1/08. . August 2008 MOR indicated a new order for Cephalexin (antibiotic) 500 mg two times a day for 10 days starting 8/19/08. The MOR indicated the medication was given for 10 days ending on the 29" which would be 20 pills. Review of the label indicated the same information and those 20 pills dispensed. Count in the container indicated 10 pills remaining even though staff signed as given. Resident only received half of ordered antibiotics. September 2008 MOR indicated to give Cephalexin 500 mg two times a day for 5 days. As of 9/4/08 there were no initials documented on MOR. Interview with staff on 9/4/08 at 2:35 PM indicated this order should not be here the antibiotic was given and completed in August 2008 and could not explain why 10 pills were remaining. Lotrimin cream was ordered to be applied daily for 15 days ending 9/8/08. The medication was not given September 1, 2, 3, 4, 2008. ; Record review of the DOEA/ALF Form 1823 health assessment for resident #12 dated 8/27/08 indicated a diagnosis of schizoaffective disorder bipolar type, organic affective disorder with confusion and psychosis. Medications ordered on the health assessment included: Risperdal (schizophrenia, bipolar disorder) 3 milligrams twice daily, Cogentin (antiparkinson's disease) 1 milligram (mg) two times a day as needed, Haldol (schizophrenia) 5 milligrams every 6 hours as needed, Ativan (anxiety) 2 milligrams every 6 hours as needed, Klonopin (seizures, panic disorder) 0.5 milligrams two times day, and Klonopin 0.5 milligrams, 2, at HS (bedtime). . In addition, Haldol and Ativan had lines drawn through them and the notation » “DIC*d 8/29/08 “. . Review of the MOR indicated: Risperdal 3 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Risperdal 3 mg given only once on 9/1/08 with no time documented. Should have been given twice daily. Cogentin 1 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Haldol 5 mg given 9/1/08 at 8:00 a.m. and 9/2/08 at 9/2/08 with no documented reason or response. This was after 16 the discontinuation date of 8/29/08. Ativan “four Ativan to equal 2 mg” given 9/1/08 at 1:00 p.m. "c/o anxiety " with no response documented. This was after the discontinuation date of 8/29/08. Ranitidine 50 mg. was given 9/1/08 once with no time documented. There was no physician order for this medication. The Klonopin was not administered as it was not on the MOR to be given. w. On 9/2/08 at 10:00 a.m. the resident exhibited erratic behavior, saw sparks coming out of the light sockets, room was in disarray, wandered in/out of other residents ' rooms and went through their belongings. Resident had to be admitted to a crisis stabilization unit for care and treatment. x. Record review for resident #1 indicated a diagnosis of myasthenia gravis and paranoid schizophrenia. Review of the MOR dated August 2008 indicated Mestinon (myasthenia gravis) 60 mg one every 8 hours for Myasthenia Gravis was refused August 2,3,4,5,6,7,9,10,11,12,13,14,22,,29,30 and on order for 8/30. Review of MOR for dates 9/1, 2 & 3 notes medication refused. y. August 2008 MOR revealed Mestinon and Cogentin were not available and “on order “August 30 and August 31, 2008. z. The record lacked documentation that family and or physician was called concerning the refusal of medication for documented diagnosis of myasthenia gravis. aa. Record review for resident #2 indicated a diagnosis of schizophrenia, dementia, Alzheimer's disease, diabetes, and Hospice for Failure to Thrive. bb. The May 2008 MOR’s indicated Morphine (narcotic analgesic) 0.25 mg two times a day on order/not available May 5-11. The following medications were not available/on order: Senna (stool softener) 2 tabs at HS (bedtime) on May 1-13, Valium (anxiety) 2 mg one every 12 hours and Trilasate (arthritis) 500 mg one, two times day on May 17 and 18. cc. September 2008 MOR indicated Refresh eye gtts (drops) daily on order/not available September 1-2. The MOR dated 5/08 indicated to give Reminyl 12 mg two times a day. No signatures noted as given and the back lacked comments on why. This was repeated on MOR’s for 8/08 and 9/08. Written on MOR by drug indicates prior authorization requested. The record lacked documentation that the pharmacy or physician was called to clarified. Staff found an order to discontinue the medication on 5/12/08 but the MOR never reflected this. , dd. Review of MOR’s for 5/08, 8/08 & 9/08 indicated the resident refused medications 57 times. ee. The record lacked documentation that the family and or physician were notified of the refusal of medications. ff. DOEA/ALF Form 1823 health assessment dated 5/11/07 revealed resident #5 had diagnoses of altered mental status, senile dementia, anxiety, depression, agitation, diabetes, and osteoporosis. gg. Review of July 2008 MOR indicated the following medications were not available/on order from the pharmacy: Viactiv Calctum Chew one three times a day was not available in facility from 7/14/08 through 7/31/08. Benadryl 25 mg one every 6 hours was not given from 7/26-31/08. Synthroid (hypothyroidism) 75 mcg one daily was not given from 7/29-31/08. Actonel (osteoporosis) 35 mg one daily was not given 7/7/08 and “on order 17 “documented. There was no documentation the medication was given the entire month of July 2008. hh. Review of August 2008 MOR indicated the following medications were not available/on order from pharmacy: Viactiv Calcium Chew was not given from 8/1-15/08. Actonel (osteoporosis) 35 mg one daily was not given the entire month of August 2008 and documented “not available “. Remeron (depression) 45 mg one daily was not given August 1-2 " on order “August 8 through August 14 “on order” August 15-22 circled as not given (19" is blank) August 26 circled as not given. Risperdal (schizophrenia, bipolar disorder) 2 mg daily was circled as not given August 1 resident refused and August 17, 19, 22, 26-31 were all blank. ii. Record review of chart notes dated 6/22/08 indicated resident has rash with severe itching, possible scabies. On 6/26/08 notes indicate the resident was treated for scabies, see Drs orders. Further record review lacked documentation that family and or physician were notified medications were not being administered as ordered by the physician. Interview with staff on 9/4/08 at 2:10 PM had no comment about why family and physician were not called. kk. DOEA/ALF Form 1823 health assessment dated 5/30/08 for resident #7 indicated diagnoses of diabetes, hypertension, and peripheral vascular disease. Il. Record review July 2008 MOR indicated the following medications were not given/on order from pharmacy: Neurontin (seizures, neuropathic pain) 100 mg one three times a day was not given 7/1-8/08. Order was changed to Neurontin 300 mg one three times a day starting 7/10/08. This medication was not given 7/10-14/08. Lactinex (promote normal bacterial flora in the intestinal tract) one three times a day was not given 7/1-30/08 and noted to be “not available “or “med on order “. Clonidine (high blood pressure) 0.1 mg. every 12 hours was ordered on August 18, 2008. The medication was circled as not given until the first dose at 8:00 p.m. on 8/20/08. The medication was circled as not given August 30-31, 2008. Blood pressure was to be taken twice daily when this medication was given. Blood pressure was only taken once a day from August 18-27, 2008 and only once daily September 1, 3, 4, and not taken at all on September 2, 2008. Blood pressure ranges from 168/108 to 124/76, mm. Review of the chart notes lacked documentation that family or physician was notified of medications not given. nn. DOEA/ALF Form 1823 with no date and incomplete revealed for resident #10 diagnoses of hypertension, arthritis, obesity, history of breast cancer and hypothyroidism. Also noted “medication administration “. oo. Record review of July 2008 MOR indicated the following medications were refused by resident: Vitamin one daily, Verapamil (angina pectoris, high blood pressure) 240 mg, Tylenol (analgesic) 325 mg two, two times a day, Clonidine (high blood pressure) 0.2 mg one two times a day, Combivent AER 2 puffs every 12 hours, Synthroid (hypothyroidism) 25 mcg one time a day, Mavik (high blood pressure) 4 mg one, one time a day, ASA 325 mg, Calcarb 600 mg, Nolvadex (breast cancer), Persantine (antiplatelet agent, vasodilator), Iron, Indapamide (high blood pressure), Micro-K (potassium), Medications were refused by resident 17 times. ; Ji- 18 Pp. qq. Ss. tt. uu. The record lacked documentation the family or physician were called. Review of the MOR dated September 2008 indicated Combivent AER inhaler was not given September 1,2,3,4, 2008. The back of the MOR stated “meds on order “, The record lacked documentation the family or physician were called. . DOEA/ALF Form 1823 dated 5/30/07 for resident #11 indicated diagnoses of chronic schizophrenia and dementia, hypertension and diabetic: Record review of August 2008 MOR indicated the following medications not given/on order from pharmacy: Risperdal (schizophrenia, bipolar disorder) 4 mg two times a day was refused 40 times. Seroquel (schizophrenia, bipolar disorder) 200 mg one time a day was refused 18 times. Namenda (dementia) 10 mg one time a day was refused 19 times. Cogentin (anti-Parkinson’s) 1 mg one time a day was refused 17 times. Verapamil (angina pectoris, high blood pressure) 120 ER one two times a day was refused 12 times and not signed as given 17 times. ASA 81 mg one time a day was refused 4 times. Vitamin one time a day was refused 7 times. Coreg (heart failure) 3.125 mg was refused 23 times. Triamcinolon cream 0.025 % two times a day was refused 34 times. Haldol (schizophrenia) 5 mg one every 4 hours was not given/on order from pharmacy August 1,2,3,4,5, 2008 then the resident refused the medication from 8/7-31/08. Review of September 2008 MOR indicated Risperdal 4 mg was not given and “on order “September 2, 3, 8, 2008. Further review of the record indicated the physician was notified 2/21/08 that the resident was refusing medications. On 5/31/08 a note indicated the resident was in the hospital and was intubated. The resident began Dialysis 6/08 and returned from hospital. The facility notified the physician the resident refuses to go to Dialysis, no mention the resident is refusing medications since 2/21/08. DOEA/ALF Form 1823 not dated and incomplete for resident #13 indicated a diagnosis of paranoid schizophrenia. . Record review of August 2008 MOR indicated Miralax 17 Grams one package daily was " not available “ August 22, 23, 24, 2008, Topamax (seizures) 25 mg two tablets two times a day was not given and documented as "not available" or "on order" August 22-27, 2008, Seroquel (schizophrenia, bipolar disorder) 200 mg two at bedtime and Seroquel 100 mg one at bedtime were not given and documented as "on order" August 23-26, 2008. Record review of September 2008 MOR indicated Bethanechol (urinary retention) 10 mg one two times a day was not given and " on order “September 1, 2008, Topamax (seizures) 25 mg two times a day was not given and " on order “September 1, 2008 and Haldol (schizophrenia) 10 mg two at bedtime and Haldol 5 mg one at bedtime was not given and " on order “September 1, 2008. Review of the record lacked documentation the family or physician was notified. ww. Record review of MOR for resident # 17 indicated Zocor (high XX, cholesterol) 20 mg half a tab at bedtime was not given and “on order “August 17-31, 2008. Further review of the record lacked evidence the family or physician was notified. Record review of MOR for resident #14 indicated Prilosec (ulcer, heartburn, gastroesophageal reflux disease) 20 mg one daily was not given and 19 documented as "on order" August 1, 2, 3, 4, 2008. Captopril (high blood pressure, heart failure) 25 mg one half tab two times a day was not given and documented as “on order “August 15-30, 2008. Flomax (benign prostatic hyperplasia) 0.4 mg one daily was not given and documented as “on order “August 29, 2008. Further record review lacked documentation the family or physician was notified. yy. Review of resident #15 MOR dated 8/08 indicated Miralax 17 gram one packet daily was not given and documented "on order" August 23- 24, 2008 and September 1, 2, 3, 2008. Ativan 2 milligrams, 1 tablet per day as needed for anxiety was given twice on August 4, 6, 8, 2008. Further record review lacked documentation the family or physician was notified. zz. Review of MOR for resident #16 indicated Advair Disk one puff two times a day was not given and documented “on order “August 7-29, 2008. Kenalog 0.1% cream was not available from August 11-26, 2008. Further record review lacked documentation that family or physician was notified. aaa. Interview with director of nursing, assistant administrator and administrator 9/4/08 5:00 PM regarding medication errors and omissions revealed staff stated we know we have problems--- we've only been here since July 2008. 38. That the failure to ensure that prescriptions for 14 (#1, 2, 3, 4, 5, 7, 10, 11,12, 13, 14, 15, 16, 17) of 22 residents were filled in a timely manner, which jeopardized the health of residents #3, #4 and #12, the same being in violation of law. 39. That the Agency determined that this deficient practice presented an imminent danger to the residents and serious physical or emotional harm would result and cited Respondent for a State Class I deficiency. 40. The regulatory provisions of the Fla. Admin. Code (2007) that is pertinent to this alleged violation read as follows: . 58A-5.0185 (7)(f) Medication Practices. MEDICATION LABELING AND ORDERS. The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self- administration of medication or medication administration are filled or refilled in a timely manner, WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 20 58A-5.0185 (7)(f) Florida Admin. Code. COUNT VII Respondent failed to provide assistance with self administration of medication and had unlicensed staff administer medications (A610); facility failed to have a licensed nurse administer medications and facility failed to administer psychiatric medications in accordance with the physician order (A613); failed to maintain an accurate medication observation record (A615); facility failed to store medications in a locked cart out of reach of wandering and confused residents (A619); facility failed to ensure that prescriptions were filled in a timely manner (A631); facility failed to notify family, physician, responsible party of resident changes in conditions of residents (A706); facility failed to serve diets as ordered by the physician, failed to follow the menu, and failed to have therapeutic meals listed on menus(A806). 41. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 42. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 43. Based on observation, interview and record review facility failed to provide necessary care and services to resident as evidenced by facility failed to provide assistance with self administration of medication and had unlicensed staff administer medications (A610); facility failed to have a licensed nurse administer medications and facility failed to administer psychiatric medications in accordance with the physician order (A613); failed to maintain an accurate medication observation record (A615); facility failed to store medications in a locked cart out of reach of wandering and confused residents (A619); facility failed to ensure that prescriptions were filled in a timely manner (A631); facility failed to notify family, physician, 21 responsible party of resident changes in conditions of residents (A706); facility failed to serve diets as ordered by the physician, failed to follow the menu, and failed to have therapeutic meals listed on menus(A806), the same being in violation of law. 44, That the failure to provide necessary care and services to resident as evidenced by facility failed to provide assistance with self administration of medication and had unlicensed staff administer medications (A610); facility failed to have a licensed nurse administer medications and facility failed to administer psychiatric medications in accordance with the physician order (A613); failed to maintain an accurate medication observation record (A615); facility failed to store medications in a locked cart out of reach of wandering and confused residents (A619); facility failed to ensure that prescriptions were filled in a timely manner (A631); facility failed to notify family, physician, responsible party of resident changes in conditions of residents (A706); facility failed to serve diets as ordered by the physician, failed to follow the menu, and failed to have therapeutic meals listed on menus(A806). 45. That the Agency determined that this deficient practice presented an imminent danger to the residents and serious physical or emotional harm would result and cited Respondent for a State Class I deficiency. 46. The regulatory provisions of the Fla. Admin. Code (2007) that is pertinent to this alleged violation read as follows: 58A-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, (by Daly observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel 22 independently in the community. (d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in 58A- 5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. (2) SOCIAL AND LEISURE ACTIVITIES. Residents shall be encouraged to participate in social, recreational, educational and other activities within the facility and the community. (a) The facility shall provide an ongoing activities program. The program shall provide diversified individual and group activities in keeping with each resident’s needs, abilities, and interests. (b) The facility shall consult with the residents in selecting, planning, and scheduling activities, The facility shall demonstrate residents’ participation through one or more of the following methods: resident meetings, committees, a resident council, suggestion box, group discussions, questionnaires, or any other form of communication appropriate to the size of the facility. (c) Scheduled activities shall be available at least six (6) days a week for a total of not less than twelve (12) hours per week. Watching television shall not be considered an activity for the purpose of meeting the twelve (12) hours per week of scheduled activities unless the television program is a special one-time event of special interest to residents of the facility. A facility whose residents choose to attend day programs conducted at adult day care centers, senior centers, mental health centers, or other day programs may count those attendance hours towards the required twelve (12) hours per week of scheduled activities. An activities calendar shall be posted in common areas where residents normally congregate. (d) If residents assist in planning a special activity such as an outing, seasonal festivity, or an excursion, up to three (3) hours may be counted toward the required activity time. (3) ARRANGEMENT FOR HEALTH CARE. In order to facilitate resident access to needed health care, the facility shall, as needed by each resident: (a) Assist residents in making appointments and remind residents about scheduled appointments for medical, dental, nursing, or mental health services. (b) Provide transportation to needed medical, dental, nursing or mental health services, or arrange for transportation through family and friends, volunteers, taxi cabs, public buses, and agencies providing transportation for persons with disabilities. (c) The facility may not require residents to see a particular health care provider. (4) ACTIVITIES OF DAILY LIVING. Facilities shall offer supervision of or assistance with activities of daily living as needed by each resident. Residents shall be encouraged to be as independent as possible in performing ADLs. (5) NURSING SERVICES. (a) Pursuant to Section 429.255, F.S., the facility may employ or contract with a nurse to: 1. Take or supervise the taking of vital signs; 2. Manage pill-organizers and administer medications as described under Rule 58A 5.0185, F.AC.; 3. Give prepackaged enemas pursuant to a physician’s order; and ~ 23 4. Maintain nursing progress notes. (b) Pursuant to Section 464.022, F.S., the nursing services listed in paragraph (a) may also be delivered in the facility by family members or friends of the resident provided the family member or friend does not receive compensation for such services. (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility shall have a written grievance procedure for receiving and responding to resident complaints, and for residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The address and telephone number for lodging complaints against a facility or facility staff shall be posted in full view in a common area accessible to all residents. The addresses and telephone numbers are: the District Long-Term Care Ombudsman Council, 1(888)831-0404; the Advocacy Center for Persons with Disabilities, 1(800)342-0823; the Florida Local Advocacy Council, 1(800)342-0825; and the Agency Consumer Hotline 1(888)419-3456, (d) The statewide toll free telephone number of the Florida Abuse Hotline “1(800)96- ABUSE or 1(800)962-2873” shall be posted in full view in a common area accessible to all residents. . (e) The facility shall have a written statement of its house rules and procedures which shall be included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. The rules and procedures shall address the facility’s policies with respect to such issues, for example, as resident responsibilities, the facility’s alcohol and tobacco policy, medication storage, the delivery of services to residents by third party providers, resident elopement, and other administrative and housekeeping practices, schedules, and requirements. (f) Residents may not be required to perform any work in the facility without compensation, except that facility rules or the facility contract may include a requirement that residents be responsible for cleaning their own sleeping areas or apartments. If a resident is employed by the facility, the resident shall be compensated, at a minimum, at an hourly wage consistent with the federal minimum wage law. (g) The facility shall provide residents with convenient access to a telephone to facilitate the resident’s right to unrestricted and private communication, pursuant to Section 429.28(1)(d), F.S. The facility shall not prohibit unidentified telephone calls to residents. For facilities with a licensed capacity of 17 or more residents in which residents do not have private telephones, there shall be, at a minimum, an accessible telephone on each floor of each building where residents reside. (h) Pursuant to Section 429.41, F.S., the use of physical restraints shall be limited to half bed rails, and only upon the written order of the resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s representative. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance shall not be considered a physical restraint. (7) THIRD PARTY SERVICES. Nothing in this rule chapter is intended to prohibit a resident or the resident’s representative from independently arranging, contracting, and paying for services provided by a third party of the resident’s choice, including a licensed 24 home health agency or private nurse, or receiving services through an out-patient clinic, provided the resident meets the criteria for continued residency and the resident complies with the facility’s policy relating to the delivery of services in the facility by third parties. The facility’s policies may require the third party to coordinate with the facility regarding the resident’s condition and the services being provided. Pursuant to subsection (6), the facility shall provide the resident with the facility’s policy regarding the provision of services to residents by non-facility staff. (8) ELOPEMENT STANDARDS. (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement shall be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility shall make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff attention shall be directed towards residents assessed at high risk for elopement, with special attention given to those with Alzheimer’s disease and related disorders assessed at high risk. 2. Ata minimum, the facility shall have a photo identification of at risk residents on file that is accessible to all facility staff and law enforcement as necessary. The photo identification shall be made available for the file within 10 calendar days of admission. In the event a resident is assessed at risk for elopement subsequent to admission, photo identification shall be made available for the file within 10 calendar days after a determination is made that the resident is at risk for elopement. The photo identification may be taken by the facility or provided by the resident or resident’s family/caregiver. (b) Facility Resident Elopement Response Policies and Procedures. The facility shall develop detailed written policies and procedures for responding to a resident elopement. At a minimum, the policies and procedures shall include: 1. An immediate staff search of the facility and premises; 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities; 3. The identification of staff responsible for contacting law enforcement, the resident’s family, guardian, health care surrogate, and case manager if the resident is not located pursuant to subparagraph (8)(b)1.; and 4. The continued care of all residents within the facility in the event of an elopement. (c) Facility Resident Elopement Drills. The facility shall conduct resident elopement drills pursuant to Sections 429.41(1)(a)3. and 429.41(1)(), F.S. (9) OTHER STANDARDS. Additional care standards for residents residing in a facility holding a limited mental health, extended congregate care or limited nursing services license are provided in Rules 58A-5.029, 58A-5.030 and 58A-5.031, F.A.C., respectively. * KOK WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 58A- 5.0182 Fla. Admin. Code (2007). 25 COUNT VIII Respondent failed to notify family, physician, or responsible party of resident changes in condition for 3 of 22 residents #3, #4, #12. 47. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 49. Based on record review, complainant and staff interview it was determined the facility failed to notify family, physician, responsible party of resident changes in condition for 3 of 22 residents #3, #4, #12, the same being in violation of law. The findings include: a. Review of resident #3 's Department of Elder Affairs/Assisted Living Facility (DOEA/ALF) Form 1823 health assessment (no date) indicated a diagnosis of chest pain and shortness of breath and assistance with activities of daily living. A second health assessment dated 1/12/07 indicated diagnoses of chronic obstructive pulmonary disease, smoker, coronary artery disease with atrial fibulation, anxiety, agitation, dementia. This assessment included a physician order for Nitroglycerin (angina pectoris) 0.3 milligrams (mg.) patch on at 0600 and off at 2200. Hospice progress notes dated 8/28/08 indicate diagnosis of debility. Review of medication observation record (MOR) indicated the following: May 2008 indicated the resident to receive Nitro-Dur 0.3 mg every morning and remove every evening. The following dates indicate initials that are circled: May 2, May 2, May 3, May 4, May 5, May 6, and 7/08. Interview with staff on 9/3/08 at 10:00 AM stated we circle our initials when the resident refuses or the medication was not given and document why on the back of the MOR. Review of the back of the May 2008 MOR revealed staff notation for 5/1-7/08 stating Nitro-patch on order. Another MOR dated May 2008 indicated Nitro-patch ON at 8:00 a.m. was circled (not given) May 8, 9, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25 and on the back of the MOR it was documented for 5/5, 5/8, 5/9, 5/10 on order/not available. June 2008 indicated Nitro-patch circled on June 26, 27, 28, 29, 30 and on the back documented not available for 6/26, 6/27, 6/28, 6/29, 6/30. Protonix (erosive esophagitis associated with gastro-esophageal reflux disorder) was circled as not given on June 27, 28, 29, blank on 30 and 31; and on the back documented on order 6/28/08, 6/29/08, and 6/31/08. July 2008 indicated Nitro-patch was circled as not given July 1, 2, 3, 4, 5, 6, and on the back documented not available July 1,2,3,5,6,7,8,9,10, and 11. August 2008 indicated Nitro-patch not available for the following dates: 26 fg August 12 and 14. Lexapro (major depressive disorder) 10 mg was not available on 8/5/08. Amaryl (diabetes) 1 mg was not available August 2 and 3. Ultram (analgesic) 50 mg not available August 2-3. Review of Hospice progress notes from 8/13/08-8/25/08 indicate resident had wheezing and rhonchi, no pain, good appetite; gets up and out to smoke and eat meals, denies pain, edema in feet/ankles continues up to 2+ at times, thonchi; dated 8/25/08 indicated resident continues to have irregular pulse with lower extremity pitting edema 2 + at feet with 1+ at mid shins. Has respiratory wheezing and rhonchi, refuses respiratory treatment or oxygen. Resident becomes short of breath with ambulation of 40 feet. Mental status prevents resident from comprehending results of non-compliance with treatment orders. Interview with administrator 9/4/08 2:10 PM stated the resident went to the emergency room on 8/30/08. She stated she was on call for the facility and received a call stating the resident was short of breath, B/P 160/110 and face very red. Review of the record including the chart notes lacked documentation that the missed medications listed above were called to the family and or physician. The record also lacked documentation about the resident becoming ill 8/30/08 and being admitted to the hospital. The resident was still in the hospital as of 9/5/08. Review of resident #4 's DOEA/ALF Form 1823 health assessment dated 1/10/08 indicated a diagnosis of schizoaffective disorder depressive type. Record review of MORs indicated the following: May 2008 an order for Vistaril (anxiety) 25 mg for anxiety as needed ordered 1/08. Vistaril was given for anxiety 18 times in the month of May 2008. June 2008 the resident received Vistaril 15 times. Review of the MOR's prior to May 2008 revealed the resident did not require that many doses of anti- anxiety medications. Review of the chart notes dated 7/13/08 indicated the resident cut her wrist with a razor, sprayed self with hairspray and threatened to set self on fire. Resident was transported to hospital and was admitted to a psychiatric unit. The resident returned to the assisted living facility on 7/17/08. August 2008 MOR indicated Effexor (major depressive disorder, general anxiety disorder, social anxiety) was not available/on order August 1-21 and August 24-26. . The September 2008 MOR indicated Effexor not given 9/1/08, not available. Other medications that were not available as indicated on the MOR's include: Lescol for high cholesterol not given 8/1-11/08 with notation written on MOR stating authorization required. Protonix (erosive esophagitis associated with gastro-esophageal reflux disorder) 40 mg one a day was not given 8/5-31/08, 9/1 and 2/08 with notation on back of MOR stating prior authorization needed. On 9/1/08 notation written on MOR stating order change. Reglan (gastro-esophageal reflux disorder) 5 mg three times a day was not given 2 times 9/1/08. August 2008 MOR indicated a new order for Cephalexin (antibiotic) 500 mg two times a day for 10 days starting 8/19/08. The MOR indicated the medication was given for 10 days ending on the 29" which would be 20 pills. 27 50. < Review of the label indicated the same information and those 20 pills dispensed. Count in the container indicated 10 pills remaining even though staff signed as given. Resident only received half of ordered antibiotics. September 2008 MOR indicated to give Cephalexin 500 mg two times a day for 5 days. As of 9/4/08 there were no initials documented on MOR. Interview with staff on 9/4/08 at 2:35 PM indicated this order should not be here the antibiotic was given and completed in August 2008 and could not explain why 10 pills were remaining. Lotrimin cream was ordered to be applied daily for 15 days ending 9/8/08. The medication was not given September 1, 2, 3, 4, 2008. Review of facility records revealed no evidence facility staff notified the resident's physician or responsible party of the change of condition or the missed medication doses. Record review of “chart notes " revealed resident was admitted 8/29/08 at 1:00 p.m. Record review of the DOEA/ALF Form 1823 health assessment for resident #12 dated 8/27/08 indicated a diagnosis of schizoaffective disorder bipolar type, organic affective disorder with confusion and psychosis. Medications ordered on the health assessment included: Risperdal (schizophrenia, bipolar disorder) 3 milligrams twice daily, Cogentin (antiparkinson's disease) 1 milligram (mg) two times a day as needed, Haldol (schizophrenia) 5 milligrams every 6 hours as needed, Ativan (anxiety) 2 milligrams every 6 hours as needed, Klonopin (seizures, panic disorder) 0.5 milligrams two times day, and Klonopin 0.5 milligrams, 2, at HS (bedtime). In addition, Haldol and Ativan had lines drawn through them and the notation “DiC‘d 8/29/08 “. Review of the MOR indicated: Risperdal 3 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Risperdal 3 mg given only once on 9/1/08 with no time documented. Should have been given twice daily. Cogentin 1 mg on 8/30/08 at 8:00 a.m. not given as evidenced by initials circled for that time and day. Haldol 5 mg given 9/1/08 at 8:00 a.m. and 9/2/08 at 9/2/08 with no documented reason or response. This was after the discontinuation date of 8/29/08. Ativan “four Ativan to equal 2 mg” given 9/1/08 at 1:00 p.m. "c/o anxiety " with no response documented, This was after the discontinuation date of 8/29/08. Ranitidine 50 mg. was given 9/1/08 once with no time documented. There was no physician order for this medication. The Klonopin was not administered as it was not on the MOR to be given. . On 9/2/08 at 10:00 a.m. the resident exhibited erratic behavior, saw sparks coming out of the light sockets, room was in disarray, wandered in/out of other residents ' rooms and went through their belongings. Resident had to be admitted to a crisis stabilization unit for care and treatment. Review of facility records revealed no evidence facility staff notified the resident's physician or responsible party of the change of condition or the missed medication doses. That the failure to notify family, physician, or responsible party of resident changes in condition for 3 of 22 residents #3, #4, #12, the same being in violation of law. 28 51. That the Agency determined that this deficient practice presented an imminent danger to the residents and serious physical or emotional harm would result and cited Respondent for a State Class I deficiency. 52. The regulatory provisions of the Fla. Admin. Code (2007) that is pertinent to this alleged violation read as follows: 58A-5.0182 (1)(d) Resident Care Standards. SUPERVISION. Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. * OK WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 58A-5.0182 (1)(d) Florida Admin. Code. COUNT IX Respondent failed to follow the menu and failed to serve therapeutic diets as ordered by the physician for 8 (#3, 9, 10, 16, 18, 19, 21, 22) of 22 sampled resident. 53. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 54. That on September 4, 2008, the Agency conducted an assisted living facility complaint survey of the Respondent facility. 55. Based on observation and record review it was determined the facility failed to follow the menu and failed to serve therapeutic diets as ordered by the physician for 8 (#3, 9, 10, 16, 18, 19, 21, 22) of 22 sampled resident, the same being in violation of law. The findings include: a. Review of the current menu indicated only regular diets are served with no concentrated sweets and no added salt. Interview with administrator, assistant administrator, and director of nursing on 9/4/08 at 1:40 PM stated we don't 29 serve any diets other that regular. b. Record review of the health assessment (HA) for resident #3 indicated a diagnoses of chest pain and shortness of breath with an order for Low Fat/Low Cholesterol diet. c. Record review of the HA for resident #9 indicated a diagnosis of diabetes mellitus (DM) with an order for a diabetic diet. d. Record review of the HA for resident #16 indicated a diagnosis of DM with an order for diabetic dict. , ¢. Record review of the HA for resident #18 indicated a diagnosis of (DM) with a diet order for 1800 calorie diet. f. Record review of the HA for resident #19 indicated a diagnosis of DM with an order for diabetic diet. g. Record review of the HA for resident #21 indicated a diagnosis of DM with an order for 1800 calorie diet. h. Record review of the HA for resident #22 indicated a diagnosis of DM with an order for 1800 calorie diet. i. There was no evidence the facility had menus for Low Fat/Low Cholesterol, Diabetic or 1800 Calorie diets and there was no evidence the residents with these diet orders received a therapeutic diet in accordance with these restrictions. j. Observation 9/3/08 and 9/4/09 at 8:00 AM on the special care unit revealed resident #10 asking for coffee during breakfast. Interview with administrator, assistant administrator, and director of nursing at the same time stated that coffee is on the menu, however, they can't have coffee on the special care unit because coffee is hot and residents might burn themselves. 56. The failure to follow the menu and failed to serve therapeutic diets as ordered by the physician for 8 (#3, 9, 10, 16, 18, 19, 21, 22) of 22 sampled residents, the same being in violation of law. 57. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 58. The regulatory provisions of the Fla. Admin. Code (2007) that is pertinent to this alleged violation read as follows: 58A-5.020 (1)(c) Food Service Standards. GENERAL RESPONSIBILITIES. When food service is provided by the facility, the administrator or a person designated in writing by the administrator shall: provide regular meals which meet the nutritional needs of residents, and therapeutic diets as ordered by the resident’s health care provider for resident’s who require special diets. 30 WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 58A-5.020 (1)(c) Florida Admin. Code. COUNT X 59. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and the remainder of this Complaint as if fully recited herein. 60. That the Agency may revoke any license issued under Part I of Chapter 429 Florida Statutes (2007) for the citation of three (3) or more cited Class I deficiencies, three (3) or more cited Class II deficiencies that have been cited on a single survey and have not been corrected within the specified time period. Section 429.14(1) (e) Florida Statutes (2007). 61. That the Respondent has been cited five (5) widespread State Class I deficiencies (Counts I, II, Ill, VI, VID, two (2) isolated State Class I deficiencies, and one widespread State Class II deficiency on an Agency complaint visit on September 4, 2008. 62. That the Agency may revoke any license issued under Section 408.815(1) (d), Florida Statutes (2007) for a demonstrated pattern of deficient performance. 63. That based thereon, the Agency seeks the revocation of the Respondent’s licensure as its primary relief. 64. That should the Respondent admit the facts herein by action or inaction, the Petitioner shall enter an Order revoking the Respondent’s. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§ 408.815(1) (d) and 429.14(1) (e), 31 Florida Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I through Count IX; (B) Recommend an administrative fine against Respondent in the amount of $37,000 for Count I, I, II, IV, V, VI, VII, VII, [X, as well as a survey fee of $500.00, pursuant to Sections 400.419(10), Florida Statutes (2007). (C) Revoke Respondent’s Assisted Living Facility License number 7258; (D) Assess attorney’s fees and costs; and (E) Grant all other general and equitable relief allowed by law. Respectfully submitted this day of September 2008 Bart O. Moore, Esquire Fla. Bar. No. 0768715 Counsel for Petitioner u Agency for Health Care Administration S 2727 Mahan Drive, MS #3 Pel “shassec, Florida 32308 1 So Ly p A» , be LZ, e 7~ pursuant to Section ented by an attorney Ae. ° . attached Election of Cp fb) 22/0 SS re Administration, and > 727 Mahan Drive, Bldg RESPOw. J REQUEST A HEARING WITHIN 21 Da. WILL RESULT IN AN SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY - m 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: Adyvenne Tay\oe- AD) Wglng SY. Ponsachia FL D. NEN odin l7 24 fes If YES, enter delivery address below: [1 No ice Type Certified Mail (Express Mail, O Registered C Return Receipt for Merchz CG Insured Mail Oc... 4; Restricted Delivery? (Extra Fee) 2. Article Number 7004 2850 OD00 552b 8558 (Transfer from PS Form 3811, February 2004 Domestic Return Receipt 402595-02- U.S. Postal Services: mee CERTIFIED-MAIL.. 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February 2004 Domestic Return Receipt 102595- U.S. Postal Service: CERTIFIED MAIL... RECEIPT. (Domestic Mail Only; No:Insurance Coverage Provide For delivery information visit our website at www.usps.coms OFFICIAL USE fs 7004 2850 0000 552b 8534 PS:-Form 3800; June.2002 SeeReverse for insti SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY A. Signature ~ ™ Complete items 1, 2, and 3, Also complete item 4 if Restricted Delivery is desired. x74... bag? 0 _ ll Print your name and address on the reverse Chint Ylilingirirg "so that we can return the card'to you. B. Received by (Printed Name) _ Receiv ™@ Attach this card to the back of the mailpiece, = “fey or on the front if space permits. / Eth ws i hig D. fs delivery address different from item 1? [1 Ye If YES, enter delivery address below: ON 1. Article Addressed to: Blaine Wilhams BBddmes River Pd | QreLe VL Gilt arn ° frenster trom service las 7004 2890 0000 552b 8541 : PS Form 3811 , February 2004 Domestic Return Receipt 102595- 3. ice Type ified Mail. [J Express Mail istered 0) Return Receipt for Merc © Insured Mail Ocop. 4, Restricted Delivery? (Extra Fee) U.S. Postal Service: CERTIFIED MAIL... RECEIPT. (Domestic. Mail Only;'No.insurance-Coverage Providea For delivery information visit our website at www.usps.coms OFFICIAL USE 7004 2890 DOOD 552b 8541 PS Form. 3800. Jiine 2002: See. Reverse for instr

Docket for Case No: 08-005413