STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2010009876 Return Receipt Requested: v. 7009 0080 0000 0586 1343 VILLA MARGO V., INC. d/b/a VILLA MARGO V, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Villa Margo v., Inc. d/b/a Villa Margo V (hereinafter “Villa Margo Vv”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes. (2009), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,500.00, pursuant to Sections 429.14 and 429.19, Florida Statutes (2009), for the protection of public health, safety and welfare. Filed February 9, 2011 4:26 PM Division of Administrative Hearings JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2009), and Chapter 28-106, Florida Administrative Code (2009). 3. Venue’ lies pursuant to Section 120.57, Florida Statutes (2009), and Rule 28-106.207, Florida Administrative Code (2009). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part, I, Florida Statutes (2009), and Chapter 58A-5 Florida Administrative Code (2009). 5. Villa Margo V operates a 14-bed assisted living facility located at 3277 S. W. 22 Terrace, Miami, Florida 33145. Villa Margo V is licensed as an assisted living facility under license number 9538. Villa Margo V was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I VILLA MARGO V FAILED TO COMPLETE A HEALTH ASSESSMENT FOR FACILITY RESIDENTS. SECTION 429.26(4), FLORIDA STATUTES RULE 58A~5.0181(2) (a), FLORIDA ADMINISTRATIVE CODE (ADMISSIONS CRITERIA STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Villa Margo V was cited with three (3) Class III deficiencies as a result of operation Spot Check surveys that were conducted on June 24, 2010 and August 25, 2010. 8. An Operation Spot Check survey was conducted on June 24, 2010. Based on interview, it was determined that the facility failed to complete a Health Assessment for 11 out of 11 facility residents (admission dates unknown). The findings include the following. 9. Facility visit on 6/24/2010 revealed there were 7 residents in the facility and 4 residents at the hospital at the time of the Operation Spot Check survey. 10. Interview with the owner/administrator on 6/24/2010 at approximately 10:30 AM revealed that in fact, the facility had not completed a Health Assessment for 11 facility residents. 11. Resident records were not presented to the surveyor during the duration of the visit. 12. The mandated date of correction was designated as August 15, 2010. 13. A follow-up survey was conducted on August 25, 2010. Based on record review and interview, it was determined that the facility still failed to have medical examination for one out of three sampled residents (Resident #3). The findings include the following. 14. Resident records review on 8/25/2010 at approximately 10:00 AM revealed that Resident #3 admitted on 7/24/2010 lacked documentation regarding physician examination (Health Assessment). 15. Interview conducted with the facility administrator on 8/25/2010 at approximately 1:00 PM confirmed the findings. This is an uncorrected deficiency from the survey of June 24, 2010. 16. Based on the foregoing facts, Villa Margo V violated Section 429.26(4), Florida Statutes, and Rule 58A-5.0181(2) (a), Florida Administrative Code, herein classified as an uncorrected, Class III violation, which warrants an assessed fine of $500.00. COUNT II VILLA MARGO V FAILED TO ENSURE THAT STAFF ASSISTED WITH SELF- ADMINISTERED MEDICATION INSTEAD OF PRE-POUR MEDICATIONS. SECTION 429.256(3) (b), FLORIDA STATUTES RULE 58A-5.1085(3), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS III VIOLATION 17. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 18. An Operation Spot Check survey was conducted on June 24, 2010. Based on observation and interview, it was determined that the facility to ensure that staff assisted with self- administered medications instead of pre-pour medications. The findings include the following. 19. Observation during facility tour on 6/24/2010 at approximately 9:30 AM revealed that the medications were being pre-poured in plastic containers with the residents’ name on it. 20. Interview with the facility staff revealed that in fact the medications for 8:00 AM were pre-poured. The facility staff is not a Registered Nurse or a Licensed Practical Nurse. 21. The mandated date of correction was designated as August 15, 2010. 22. A follow-up survey was conducted on August 25, 2010. Based on observation and staff interview the facility still failed to ensure that staff assisted with self administered medications instead of providing medications for Resident #6. The findings include the following. 23. Observation of assistance with self-administered medication on 8/25/2010 at 2:00 PM revealed the administrator and Staff #2 brought a glass of water and the bingo card of Hydroxizine Pam 25mg capsule to the resident who was sitting on his wheelchair in the living room; they asked the resident to open his hand and placed a pill on the resident's hand and gave him the glass of water. Staff and administrator did not read the medication label to the resident. 24, Interview with administrator on 8/25/2010 at approximately 2:20pm revealed they were trained to check the resident's name on the label and either place the pill from the bingo card on the resident's hand or put it on a plastic cup in front of the resident. Said she was not aware label had to be read in front of the resident and tell him the medication name and what it was for. This is an uncorrected deficiency from the survey of June 24, 2010. 25. Based on the foregoing facts, Villa Margo V violated Section 429.256(3) (b), Florida Statutes, and Rule 58A-5.0185(3), Florida Administrative Code herein classified as an uncorrected, Class III violation, which warrants an assessed fine of $500.00. COUNT III VILLA MARGO V FAILED TO ENSURE CENTRALLY STORED MEDICATION WERE KEPT IN A LOCKED CABINET. RULE 58A-5.0185(6) (b), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS III VIOLATION 26. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 27. An Operation Spot Check survey was conducted on June 24, 2010. Based on observation and staff interview, it was determined that the facility failed to ensure centrally stored medications were kept in a locked cabinet at all times. The findings include the following. 28. During facility tour conducted on 6/24/2010 at approximately 9:40 AM medications were found in an unlocked cabinet in the common area, kitchen cabinets, and in the dining area where residents could have access to it. 29. The cabinet, used to store all the residents’ medications, located in the common area, was not locked. Surveyor then observed Flu relief therapy, Anti Diarrheal, Day Quick, Lactulose Sodium, Alendronate Sodium used by Resident #9, Isopropyl 70% rubbing alcohol, Phenytoin 125 mg/5ml on top of the medication cabinet. Zinc Oxide 2% ointment used by Resident #8 (discharged resident) was on the top of the dining table. In addition, Ibuprofen 200 mg, Aspirin 81 mg, Nausea Control, Gas Relief, Zolpidem Tartrate 10 mg used by Resident #7 (discharged resident) were found unlocked inside the kitchen cabinets. 30. Interview with the owner/administrator on 6/24/2010 at approximately 10:30 AM confirmed the findings. 31. The mandated date of correction was designated as August 15, 2010. 32. A follow-up survey was conducted on August 25, 2010. Based on observation and staff interview, it was determined that the facility still failed to ensure centrally stored medications were kept in a locked cabinet at all times. The findings include the following. 33. During facility tour conducted on 8/25/2010 at approximately 10:00 AM over the counter medications were observed unsecured inside a drawer in an armoire located in the “TV room: 1 box of Visine eye drops % fld oz; 1 box of Sanafitil antifungal liquid 2 fl oz; 1 box of Hemorrodil cream 28g; ‘4 bottle of Dorzolamide Hydrochloride Tomolol Maliate phtalmic solution. 34. Interview conducted with the facility administrator on 8/25/2010 at approximately 12:45 PM revealed these medications belonged to the staff. He/she has provided them with a locked drawer on this same armoire, but they failed to store these 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 the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF. YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER Letecets Dlowcrore ap Lourdes A. Naranjo, B Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53%¢ Street Suite 300 Miami, Florida 33166 Copies furnished to: R. Steve Emling Field Office Manager Agency for Health Care Administration 8333 N. W. 53°¢ Street - Suite 300 Miami, Florida 33166 (Interoffice Mail) 10 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Margarita Piloto, Administrator, Villa Margo V, 3277 § . 22° ferrace, Miami, Florida 33145 on this 5.., of Breer ere 2011. 11 70095 OO80 Go00 0586 1343 _ US. Postal Service 1 CERTIFIED MAIL:..8 Domestic Mall Only; No tise ce uneR. COMPLETE THIS SECTION For. deliffety Information visit our:y, Carnie ie . so that we can return'the card to you. ft Attach this card to the back of the mallplece, Cerilled Feo or on the front if space permits. i (encorecrran eet ee 1. Article Addressed to: . Fe “| otnt cena Mangarita, Pa loti Total Postage & Fees ig | ‘ Uda. H ONG ve ‘ so Paik, S274 SW.22 Tonnace BA Aan Pr lote . vp ie go siesta NaS ita... Vitamui: Flees 33046 oho BOND 4094. Ow D2) Ciliy Stale, Pa r Me dams fara {PS Forte 3800; August 2006." 9 70045 0080 Oo00 0586 1343 COMPLETE THIS SECTION ON DELIVERY Di 1a deliery address AYES, t liv ‘Mall a Receipt for. Merchandise Cl yes |___ (Transfer from service label) | PS Form 3811, February 2004 _ Domestic Return Recel pt Uda, at rf ty CompiiP2895-02-M1540 |

Docket for Case No: 11-000676

Orders for Case No: 11-000676