STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2010007538 ALBINA MANOR, LLC, d/b/a ALBINA MANOR, 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 Albina Manor, LLC, d/b/a Albina Manor (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2010), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of five hundred dollars ($500.00) based upon one (1) cited uncorrected State Class III deficiency pursuant to §429.19(2)(c), Florida Statutes (2010), and the imposition of a survey fee of five hundred dollars ($500.00) pursuant to the provisions of § 429.19(7), Florida Statutes (2010) for a total assessment of one thousand dollars ($1,000.00). 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 (2010). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. Filed October 18, 2010 2:12 PM Division of Administrative Hearings. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a twenty-two (22) bed assisted living facility located at 820 is® Street North, Saint Petersburg, Florida 33705, and is licensed as an assisted living facility, license number 9774. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with ail 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, no prescription drug shall be kept or administered by the facility, including assistance with self-administration of medication, unless it is properly labeled and dispensed in accordance with Chapters 465 and 499, F.S., and Rule 64B16-28.108, F.A.C. If a customized patient medication package is prepared for a resident, and separated into individual medicinal drug containers, then the following information must be recorded on each individual container: 1. The resident’s name; and 2. Identification of each medicinal drug product in the container. Rule 58A-5.0185(7)(a), Florida Administrative Code. 8. That on June 2, 2010 the Agency conducted a Complaint inspection CCR #s 2010002714, 2010004143, and 2010005457, of the Respondent facility. 9. That based upon observation and the review of records, Respondent failed to maintain appropriately labeled medications Respondent kept or administered for one (1) of seven (7) sampled residents, the same being contrary to law 10. That Petitioner’s representative toured the Respondent facility on June 1, 2010 and noted the following: a. Two (2) boxes of medications were sitting on a dresser in room number five (5); b. One of the medications was Albuterol Sulfate 0.83% with no pharmacy label on the box; c. The second medication box contained Ipratropium Bromide 0.02% with a pharmacy label which read “inhale 1 vial mixed with Albutero! via nebulizer every 6 hours.” d. That neither of these medication containers was labeled as required by law. 11. The Respondent did have prescriptions in the records of resident number five (50 for both medications, 12. That the above reflects Respondent’s failure to ensure that all resident medications are properly labeled and dispensed in accord with law, the same placing resident’s at risk of medication error. 13. That the Agency determined that this deficient practice was related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations, and cited Respondent for a Class III deficient practice. 14. That the Agency provided a mandated correction date of July 1, 2010. 15. That on July 2, 2010 the Agency conducted a re-visit to Complaint inspection CCR #s 2010002714, 2010004143, and 2010005457, of the Respondent facility. 16. That based upon observation, interview, and the review of records, Respondent failed to maintain appropriately labeled medications Respondent kept or administered for one (1) of three (3) sampled residents, the same being contrary to law 17. _ That Petitioner’s representative reviewed Respondent’s records related to resident number three (3) and noted as follows; a. The resident’s health assessment, form 1823, dated May 20, 2010, indicated the resident needed assistance with medications; b. Prescribed medications included Nitrostat, chest pain, 0.4 mg, 1 tablet under tongue at onset, may repeat in 5 minutes no more than 3 times and Aspirin 325 mg., | tablet by mouth daily. 18. That Petitioner’s representative observed Respondent’s bin in which medications were maintained for resident number three (3) on July 2, 2010 at 10:30 AM and noted a bottle of Nitrostat and Aspirin. 19, That neither of the containers of the medications addressed above contained a label indicating the resident’s name, dosage, or instructions for use. 20. That Petitioner’s representative interviewed Respondent’s Administrator regarding these medications on July 2, 2010 at approximately 10:30 Am who confirmed that the Nitrostat and Aspirin belonged to resident number three (3) and that the medication containers did not have labels reflecting the resident’s name, dosage, or instructions for use. 21. That the above reflects Respondent’s failure to ensure that all resident medications are properly labeled and dispensed in accord with law, the same placing resident’s at risk of medication error. 22. That the Agency determined that this deficient practice was related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class ] or class II violations, and cited Respondent for a Class III deficient practice. 23. That the same constitutes an uncorrected Class III deficient practice as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2010). COUNT II 24. That the Agency re-alleges and incorporates paragraphs (1) through (5) and Count J as if fully set forth herein. 25. That pursuant to Section 429.19(7), Florida Statutes (2010), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2010), to verify the correction of the violations. 26. That on July 2, 2010 the Agency conducted a re-visit to Complaint inspection CCR #s 2010002714, 2010004143, and 2010005457, of the Respondent facility and cited Respondent with deficient practices which were the subject of the complaint, including but not limited to the deficient practice more fuloly described in Count I of this Complaint. 27. That pursuant to Section 429.19(7), Florida Statutes (2010), such a finding subjects the Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or $500.00. 28. That Respondent is therefore subject to a complaint survey fee of five hundred dollars ($500.00), pursuant to Section 429,19(7), Florida Statutes (2010). WHEREFORE, the Agency intends to impose an additional survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(7), Florida Statutes (2010). Respectfully submitted this g day of September 2010. 2 ThonayJ. Walsh II Fla/Bér. No. 566365 Cotinsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg 43,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE US. Certified Mail, Return Receipt No. 7004 2890 0000 5526 6943 on September 2010, to Richard M. Sebek, Esq., Counsel for Respondent Albina Manor LLC, 501 East Kennedy Boulevard, Suite 1600, Tampa, Florida 33602, I HEREBY CERTIFY that a true and correct copy of the foregoing has pz by Tamas J. Walsh II ¢Senior Attoney la Copy furnished to: Richard M. Sebek, Esq. Patricia R. Caufman Thomas J. Walsh II, Esq. Counsel for Respondent Field Office Manager Agency for Healthcare Admin. Albina Manor LLC 525 Mirror Lake Drive, 525 Mirror Lake Drive North, 501 East Kennedy Boulevard 4" Floor Suite 330G Suite 1600 St. Petersburg, FL 33701 St. Petersburg, FL 33701 Tampa, Florida 33602 (Interoffice) (Interoffice) (U.S. Certified Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Albina Manor, LLC, CASE NO. 2010007538 d/b/a Albina Manor, ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) _ | I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. | understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2)_ | I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)___—Ss I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) I hereby certify that | am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title:_ Late fee/fine/AC ION ON DELIVERY COMPLETE THIS SEC. SENDER: COMPL. ™ Complete items 1, _, ..1d 3. Also complete item 4 if Restricted Delivery is desired. ™ Print your name and address on the reverse ; _ $0 that we can raturn the card to you. @ Attach this card to the back of the maliplace, or on the front if space permits. . 1. Articla Addressed to: Richard M. Sebel, Esq. Counsel for Respondent Albina Manor LLC 501 East Kennedy Blvd. = Suite 1600 Tampa, Florida 33602 HIS SECTION D. Is delivery address different from item 17 CL Ya If YES, enter delivery address below: [1 No cd 2 Return Receipt for Merchand ae ?004 2890 COO ssau 4443 Te 2 ’ PS Form 3811, February 2004 Oomestic Return Receipt 102895-02-M-1 DENG rar, Jo wos BOT “SVT SAL Tale ET ~easpisoy AB SATAY 3 sappy copmuswspiing amy econ} 20 cALEDWdYO IVLOL i ae a WAS pir ae se. mg AANGOD SWC TINEA S022 Fa ‘GAS Used LADS N ESSTHLES 11. OL OB WONWW. PNET eo a 2. 2m BPLIET,{ 40 SHATB OU: Bure capo aopy arntedo oy pox sore sy pagdaiso ny PT MONVE ‘S°VES Fi pur eprops Jo Meg OTE. 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Docket for Case No: 10-009750