STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case Nos. 2010002649 vs. INGLESIDE RETIREMENT, 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 Ingleside Retirement (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2009), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of twenty five thousand dollars ($25,000.00) based upon four cited State Class II deficiencies pursuant to § 429.19(2)(b), Florida Statutes (2009). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and Chapters 408, Part II, and 429, Part I, Florida Statutes (2009). 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 Filed April 27, 2010 10:13 AM Division of Administrative Hearings. facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part Il, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates an 18-bed assisted living facility located at 1433 Ingleside Avenue, Jacksonville, Florida 32205, and is licensed as an assisted living facility, license number 5576. 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 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, any facility intending to admit three or more mental health residents must obtain a limited mental health license from the Agency in accordance with Rule Rule 58A-5,.014, F.A.C., and Section 429.075, F.S., prior to accepting the third mental health resident. 58A-5.029(1)(a), Florida Administrative Code 8. That pursuant to Florida law, --An assisted living facility that serves three or more mental health residents must obtain a limited mental health license. (1) To obtain a limited mental health license, a facility must hold a standard license as an assisted living facility, must not have any current uncorrected deficiencies or violations, and must ensure that, within 6 months after receiving a limited mental health license, the facility administrator and the staff of the facility who are in direct contact with mental health residents must complete training of no less than 6 hours related to their duties. Such designation may be made at the time of initial licensure or re- licensure or upon request in writing by a licensee under this part and part IT of chapter 408. Notification of approval or denial of such request shall be made in accordance with this part, part Il of chapter 408, and applicable rules. This training will be provided by or approved by the Department of Children and Family Services. § 429.075(1), Florida Statutes (2009) 9, That on January 25, 2010, the Agency conducted a biennial licensure survey of the Respondent’s facility. 10. That based on resident record review and an interview with the Administrator, the facility failed to ensure that they did not accept more than two residents who received OSS (Optional State Supplementation) and qualified as mental health residents for seven of twelve residents (#1, #2, #3, #4, #5, #6 and #7) at the facility. ll. That a review of the records of 12 residents revealed that Residents #1, #2, #3, #4, ##5, #6, and #7 were all receiving OSS (Optional State Supplementation) payments and each resident had at least one major mental health diagnosis. The facility did not hold a limited mental health license and should not have accepted more than two residents receiving OSS who qualified as mental health residents. 12. That this was confirmed in an interview with the Administrator on January 25, 2010, at 1:30 P.M. 13. That the above reflects Respondent’s failure to obtain a valid license for Limited: Mental Health before taking Limited Mental Health clients. 14. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of Respondent or to the care of clients which directly threatens the physical or emotional health, safety, or security of the chents, other than class I violations, 1S. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2009). 16, That the Agency provided a mandatory correction date of February 25, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(b), Florida Statutes (2009). COUNT II 17, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. That pursuant to Florida law, if the resident no longer meets the criteria for continued residency, or the facility is unable to meet the resident’s needs, as determined by the facility administrator or health care provider, the resident shall be discharged in accordance with Section 429.28(1), F.S. Rule 58A-5.0181(5), Florida Administrative Code 18, That pursuant to Florida law, no resident of a facility shall'’be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: . (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. (c) Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. (d) Unrestricted private communication, including receiving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. at a minimum. Upon request, the facility shall make provisions to extend visiting hours for caregivers and out-of-town guests, and in other similar situations. (e) Freedom to participate in and benefit from community services and activities and to achieve the highest possible level of independence, autonomy, and interaction within the community. (f) Manage his or her financial affairs unless the resident or, if applicable, the resident's representative, designee, surrogate, guardian, or attorney in fact authorizes the - administrator of the facility to provide safekeeping for funds as provided in s. 429.27. (g) Share a room with his or her spouse if both are residents of the facility. (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather. (i) Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shal] be imposed upon any resident. (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community, (k) At least 45 days' notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents. In the case of a resident who has been adjudicated mentally incapacitated, the guardian shall be given at least 45 days' notice of a nonemergency relocation or residency termination. Reasons for relocation shall be set forth in writing. In order for a facility to terminate the residency of an individual without notice as provided herein, the facility shall show good cause in a court of competent jurisdiction. (1) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the residents' exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. 19. That on January 25, 2010, the Agency conducted a biennial licensure survey of the Respondent’s facility. 20. That based on observation, resident record review | and an interview with the Administrator, the facility failed to discharge a resident who needed care beyond the. facility's capability to provide care for one of nine residents reviewed, #1. 21, That a review of Resident #1's health assessment revealed the resident had a diagnosis of dementia. 22, That since his/hers last stay in the hospital for the treatment of cellulitis, the resident's condition had deteriorated and needed assistance beyond the current level of care identified in the health assessment. 23. That the facility had one employee working on a 24 hour, seven days a week basis. 24. That during the survey process Resident #1 needed assistance with toileting, but the employee was working in another area and'was not able to assist the resident when needed. 25, That this caused the resident to soil him/herself, which alerted another resident to obtain help for Resident #1. 26. That Resident #1 could ambulate, but required extensive cueing and personal assistance in all areas of activities with daily living. Based upon observation and interview, 27. That upon arrival at the facility at 9:00 a.m. there was no one available to provide any of the residents’ breakfast. 28. That Resident #1 was unable to prepare food for breakfast and did not eat until 1:15 P.M. 29. That the Administrator brought in additional staff to ensure all that the residents received lunch on the day of the survey. 30. That this was confirmed in an interview with the Administrator on January 25, 2010 at 3:00 P.M. 31, That the above reflects Respondent failed to discharge a resident when they were unable to meet the resident’s needs. 32. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of Respondent or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 33. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2009). 34, That the Agency provided a mandatory correction date of February 25, 2010. | WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2009). COUNT JI 35, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth _ herein. 36. That pursuant to Florida law, an assisted living 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. Rule 58A- 5.0185(7)(f) 37. That on January 25, 2010, the Agency conducted a biennial Hcensure survey of the Respondents facility. 38. That based on observation, record review, and interviews with a medication tech and the Administrator, the facility failed to ensure that prescriptions for residents, who received assistance with self-administration of medication or medication administration, were filled or refilled in a timely manner for two of three residents, #1 and #3. 39. That on January 25, 2010 at 10:30 A.M. a record review and observation of Resident #1's medications revealed that the resident was prescribed Furosemide 40 mg, take 1 tab once daily and that the medication was not available. 40. That in an interview on January 25, 2010 at 10:30 the Medication Tech stated that she did not know the last time Resident #1 received the medication. 41. That she then brought a fax from the pharmacy, dated January 6, 2010, that read there _were no refills remaining and no interventions were taken to get the refills for the medication. 42. That on January 25, 2010 at 10:40 A.M. a record review and observation of Resident #3's medication revealed that the resident was prescribed Singulair 10 mg, take 1 tab once daily and the medication was not available. 43. That in an interview on January 25, 2010 at 10:40 A.M. with the Medication Tech revealed that she had a fax from the Pharmacy, dated January 6, 2010, which read that the resident had not recieved the medication since that date. 44. That this was confirmed in an interview with the Administrator on J. anuary 25, 2010 at 11:20 am. | 45, That the above reflects Respondent’s failure to make every reasonable effort to refill . medication prescriptions in a timely manner where Respondent ordered refills knowing that the medication would be delivered after the facility stock thereof had been exhausted yet took no action to insure that there would be no break in the provision of the resident’s medications, 46. That the failure to provide medications as prescribed endangers resident health and could impact the efficacy of the clinical milieu. 47. That Respondent was aware of the delay of pharmacy delivery and the resultant absence of medications, but took no action to address this gap in the provision of prescriptive. 48. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of Respondent or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 49, That the above reflects Respondent’s failure to provide care and services appropriate to the needs of residents in Respondent’s failure to ensure that prescriptive medications are available for administration to residents or in the absence thereof for Respondent to ensure that the physician of any resident not receiving medications as prescribed are notified of this deviation from the prescriptive regime. | 50, That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of Respondent or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 51. That the Agency cited the Respondent for a Class II violation in accordance with Section 429,19(2)(b), Florida Statutes (2009), 52. That the Agency provided a mandated correction date of January 28, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2009). COUNT IV 53, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 54. That pursuant to Florida law, an assisted living facility shall provide care and services appropriate to: the needs of residents accepted for admission to the facility. 55. (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, FAC. (b) Daily 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. 56. That on January 25, 2010, the Agency conducted a biennial licensure survey of the Respondent’s facility. 57. That the allegations of Counts I, TH, and Ill of this complaint are hereby incorporated herein as if fully recited. 58. That based on observation, interviews with residents and the administrator, the facility failed to provide the appropriate care and services to the needs of 12 residents at the facility and three residents who had not appropriately received medications as ordered by a health care provider. 59. That upon arrival at the facility at 9:00 A.M., a tour revealed one person, with limited English skills, attending to the residents. 60. . That an interview with Residents #3, #4, #8, and #9 revealed that no one had prepared breakfast for the 12 residents. The person in charge was unable to explain what caused the problem. 61. That at 9:20 A.M., a staff member arrived, called the administrator and began to start morning duties without providing break fast. 62. That at 10:30 A.M., the Administrator arrived and then called for additional staff to begin to fix the residents a meal. The meal was served at 1:00 P.M. 63, That a review of Resident #3's medication observation record revealed that: a. Benztropine tab 1mg (milligrams),take 1 tab po (by mouth) BID (twice a day) 7 doses missed from January 21 to January 25, 2010. b. Mirtazapine tab 15 mg, take 1 tab po at bedtime 3 doses missed from January 22 to January 25, 2010. c. Risperidone 4 mg, take 1 tab po BID. 5 doses missed from January 22 to January 25, 2010. 63. A review of Resident #2's medication observation record revealed that: a. Haloperidal tab 10 mg, 1 tab po Q evening, 3 doses missed from January 22 to January 25, 2010. b. Carbamazepin 200 mg, 1 tab 200 mg, take 1 tab twice a day 46 doses missed from December 28, 2009 to January 25, 2010. c. Risperidone 4 mg, 1 tab po BID 14 doses missed from December 28, 2009 to January 25, 2010. d. Benztropine tab 2 mg, take 1 tab twice a day 48 doses missed from December 28, 2009 to January 25, 2010. e. Fluoxetine cap 20 mg, take 1 cap every morning 17 doses missed from December 28, 2009 to January 25, 2010. f, Haloperidol 5 mg, take 1 tab every morning and 3 tabs every evening 15 doses missed from January 20 to January 25, 2010. 64. That a review of the medication observation record for Resident #1 revealed that the resident had Lasix 40 mg once a day and Lasix had not been available to resident since January 6, 2010. 65. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of Respondent or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 66, That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2009). 67, That the Agency provided a mandatory correction date of January 28, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ° five thousand dollars ($5,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(b), Florida Statutes (2009). 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 II, III and IV; (B) Recommend an administrative fine against Respondent in the total amount of $25,000; | (C) Assess attorney’s fees and costs; and . @) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WIT HIN 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. Respectfully submitted this , g f day of March, 2010. Carlton Enfinger ° Fla, Bar.0793450 v Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.412.36300 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true.and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4970 to Facility Administrator Kimberly Ann Alli, Ingleside Retirement, 1433 Ingleside Avenue, Jacksonville, Florida 32205; and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4987 to Owner Wajad ' Alli, 8945 Shindler Crossing Drive, Jacksonville, Florida 3222 on March BY, , 2010: Copy furnished to: Robert Dickson, FOM Seb 4470 Certified Fee Postmark lore Return Recelpt Feo He (Endorsement Required) trioted Dellvery Fee (Entorsement Required) Total Postage & Faes 2004 2890 oo00 5 Hise 3 Sie ae | SENDER: COMPLETE THIS SECTION i Complete items 1, 2, and 3. Also complete F em 4 if Restricted Delivery Is desired. b4 ‘ C1 Agent ™@ Print your name and address on the reverse y d CO Addresseo so that we can return the card to you. ™ Attach this card to the back of the mailplece, or on the front if space permits. 1. Article Addressed to: If YES, enter delivery address below: [1 No TACKY Atom caer REN ely ae, wee AY Avslenidg: Celt remerce IWSx Xv. SIESTA , Arana C1 Registered CK Sonuithe | VE RAKROS 7004 2850 0000 552b 4470 PS Form 3811, February 2004 ae 1 Express Mall (1 Return Recelpt for Merchandise O Insured Mall ~=O1'.0.D. GCortitled Fee Return Recelpe re (Encorsoment Raquitesh . sere Restricted Dellve (Endorsement Rogulreah Total Postage & Feas IN Me ve 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 malipléce, or on the front if space permits : DI Agent Co Addressee D. Is delivery address different from ttem 12 C1 Yes 1. Article Addressed to: of If YES, enter delivery address below: [1 No Lok MO | Soe sy vee Ceoen dy A) algo. j ye Mall © Express Mall Whe 4 ¥ L SX C1 Registered (i Return Receipt for Merchandisé C1 Insured Mail O1c.0.b. 4, Restricted Delivery? (Extra Fee) 7004 2890-0000 552b 44a? : PS Form 3811, February 2004 Domestio Return Recelpt 102598-02-M-1840 SEUES EE USPS ~ Track & Confirm : Page | of i ay UNITED STATES. 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Docket for Case No: 10-002294