STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR me imtietabe eee HEALTH CARE ADMINISTRATION, Petitioner, VS. : Case No. 2011001630 CATALINA GARDENS HEALTH CARE ASSOCIATES, LLC, d/b/a BROOKSHIRE (THE), Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Petitioner” or “Agency”), by and thtough the undersigned counsel, and files this Administrative Complaint against CATALINA GARDENS HEALTH CARE ASSOCIATES, LLC, d/b/a BROOKSHIRE (THE) (hereinafter “Respondent”), pursuant to § 120.569 and § 120.57, Fla. Stat. (2010), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of One Thousand and No/100 ($1,000.00) Dollars and a survey fee in the amount of Five Hundred and No/100 ($500.00) Dollars based upon one (1) cited State Class II deficiency violation pursuant to § 429,19(2)(b) and § 429.19(7), Fla, Stat. (2010) for a total assessmnent of One Thousand Five Hundred and No/100 ($1,500.00) Dollars. . JURISDICTION: AND VENUE 1. The Agency has jurisdiction pursuant to § 20.42, § 120.60 and Chapters 408, Part II, and 429, Part I, Fla. Stat. (2010), Filed March 22, 2011 11:10 AM Division of Administrative Hearings 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES a ee eee on 5 The is-the regu! hori ‘ble fort € assisted liv facilities and enforcement of all applicable regulations, state statutes and rules governing assisted , living facilities pursuant to the Chapters 408, Part IJ, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates an 125-bed assisted living facility (hereafter “ALF”) located at 85 Bulidog Bivd., Melboume, Florida 32901, and is licensed as an ALF, license number 7354, 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 (Tag: A631) 6. . The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein, . 7. That pursuant to Florida law, “(t]he 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.” Fla. Admin. Code R. 58A- 5.0185(7\(f). . 8. That on 12/13/10, the Agency conducted a Complaint Investigation Survey (CCR No. 2010012963) of the Respondent’s facility, 9. That based upon interview and record review, Respondent failed or refused to make every reasonable effort to ensure that presctiptions for one (1) of eight (8) sampled residents, specifically Resident No. 8 (hereafter “R8”), who receive assistance with self-administration of medication were filled in a timely manner which resulted in R8 going without the medication and experiencing constant pain. Page 2 of 7 10. Thata confidential source stated on 12/13/10 at approximately 2:00 PM that R8 had been without pain medication for several days. Form AHCS 1823 (hereafter “1823”) dated 09/28/ 10 that indicated: diagnoses of poly kidney disease, fibromyalgia, abdominal pain, GERD, HTN, SSS and dementia. a. Per assessment, R8 was alert and. oriented to place, person and date; b, R8 required supervision . with bathing, assistance with toileting, and was. independent with ambulation, dressing, eating and grooming; and c. R8 was able to self-administer medications. . 12, That continued record review revealed that Respondent’s facility staff assisted R8 with gelf-administration of medications, as evident by the MOR and the staff signatures. 13. That Respondent’s facility note dated 10/01/10 indicated R8 was in pain and needed pain medication. R8 stated that s/he was nauseated because of the pain and nerves. The doctor was - called, 14. That the November MOR. for R8 indicated Percocet had been changed to one (1) tablet every six (6) hours for pain effective 11/16/10. The narcotic substance record indicated that Oxycodone /Apap 5/325 had “no refills” and the last pill was taken on 12/11/10 at 4:00 PM. 15. That Respondent’s facility note dated 12/13/10 indicated “Resident in need of pain med”, called. resident’s physician- resident’s information provided to doctor’s office including pharmacy name and number. 16. ‘That a nurse’s report book indicated that on 12/11/10 R8 was “completely out of pain meds”. On 12/12/10, R8 had “no Percocet -upset (to say least) needs order for Percocet”. Page 3 of 7 as 17. That medication review revealed there was no Percocet for R8. Respondent’s staff claimed the nurses ordered the medication and that was all she knew. The December MOR listed 18. That regarding R8: a. S/he was observed on 12/13/10 at approximately 5:00 PM in the dining room, attempting to eat supper; s/he was alert and oriented. b. R8 stated on 12/13/10 at approximately 5:00 PM s/he was in constant pain since s/he has been out of the medication, as fibromyalgia was very painful; the pain made her feel nauseated and ill. . c. S/he would tiot eat supper today (12/13/10), maybe crackers later on. d. S/he tried hard-to relax, to try to feel comfortable - but it did not work. e. S/he questioned that if Respondent’s facility staff were aware a refill was unavailable, and the’ doctor had to be called for a refill, why Respondent did not call the doctor before s/he ran out of the medication and avoid the delay and his/her subsequent pain. oe 19. That Respondent’s Administrator stated on 12/13/10 at approximately 5:15 PM that Respondent’s staff should reorder medications five (5) to seven (7) days before medications ron out. - 20. ° That.the Agency determined this deficient practice was related to the operation and. maintenance of a provider or to the care of clients which the Agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations and cited Respondent for a State Class II deficiency violation. 21. That the same constitutes grounds for a State Class II deficiency violation as defined by law. . Page 4 of 7 +e ontrary tote eee 22. That in the case at bar, the above reflect, inter alia, that Respondent failed to fill pain medication prescription for a resident under Respondent’s care in a timely manner, which is WHEREFORE, the Agency intends to impose an administrative fine in the amount of One Thousand and No/100 ($1,000.00) Dollars, against Respondent, an ALF in the State of Florida, pursuant to § 429,19(2)(b), Fla. Stat. (2010). . COUNT II (Survey Fee), 23. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein, . 4. That pursuant to § 429.19(7), Fla. Stat. (2010), “tin addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of.one half of the facility's ‘biennial ‘Ticense 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 8. 429,28(3)(c) to verify the correction of the violations.” 25. That pursuant to § 429,19(7), Fla. Stat. (2010), such a finding subjects Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or five hundred dollars ($500.00). 26. That Respondent is therefore subject to a survey fee of Five Hundred and No/100 ($500.00) Dollars, pursuant to § 429.19(7), Fla, Stat. (2010). WHEREFORE, the Agency intends to impose an additional survey fee of Five Hundred and No/100 ($500.00) Dollars against Respondent, an ALF in the State of Florida, pursuant-to § 429,19(7), Fla, Stat. (2010). Page 5 of 7 Respectfully submitted this { 4 ay of February, 2011. STATE .OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION __ - The Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1942 Facsimile: (727) 552-1440 E-mail: Thom: bury@ahca.myflorida.com By: ; Thomas F. Asbury, Esq. Fig. Bar No. 567523 Respondent is notified that it has a tight 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 #3, MS #3, Tallahassee, FL 32308; Telephone (850) 412-3630. 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. | Page 6 of 7 ai CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by | Theresa DeCanio US, Certified Mail; Return Receipt No 7610-0780 0001-9835 6915 on February (5201146 Respondent, ATTN: Corporation Services Company, Registered Agent, 1201 Hays Street, Tallahassee, FL 32301-2525 and via U.S. Mail to Respondent, ATTN: Leasa R. Phenix, Administrator, Brookshire (The), 85 Bulldog Blvd., Melbourne, Florida Thomas F. Asbury, Esq. Copies furnished to: Thomas F. Asbury, Esq. Agency for Health Care Admin. 525 Mirror Lake Dr. N., 330 St. Petersburg, Florida 33701 (Interoffice) Brookshire (The) ATTN: Leasa R. Phenix, Admin. 85 Bulldog Blvd. , Melbourne, Florida 32901 (U.S. Mail) Brookshire (The) ATIN: Corporation Services Company, Reg. Agent 1201 Hays Street Tallahassee, FL 32301-2525 (U.S. Certified Mail) (Interoffice) Page 7 of 7 USPS - Track & Confirm : Page 1 of 1 Home | Help | Stan In Searoh Results Label/Receipt Number: 7010 0780 0001 9835 6908 Service(s): Certified Mail™ Status: Delivered Enter a Number. Your item was delivered at 9:30 am on February 22, 2011 in semocesnoavinwo’ | TALLAHASSEE, FL 32314. / (G03) | Track & Confirm | Detailed Results: » Delivered, February 22, 2011, 9:30 am, TALLAHASSEE, FL 32314 » Arrival at Unit, February 22, 2011, 8:05 am, TALLAHASSEE, FL 32301 Notitigation Options Track & Confirm by email Get currant event information or updates for your item sent to you or others by email. Char) & Pesald Sequqoiyt [Hk OKRE Cot petin Heravher eet: hind Copyrtt" 2010.U8PS, All Rights Reserved, No FEAR ACIEEO Nala FOIA Teakneag bees {cs iene . 1 to the bag Oron the front If apes pent ‘n s maiipiece, . i 1 Article Adtirassed to; | oni Lakes Health Cggg”” "~~ 3 [- ATIN:Corporationgu '. Registered Agent YiceCompany, 4 i ra Hays Streey j- allahassee, Fy 32301-2595 http:/Arkenfrm 1 smi.usps.com/PTSInternet Web/InterLabellnquiry.do 03/17/2011 COMPLETE THIS SECTIOQLON DELIVERY Le ATTN: Leasa R. Phenix, Admin. 85 Bulldog Blvd. Melbourne, Florida 32901 o780 0001 9835 bALs bruary 2004 wo Domestio Retum Fecalpt .

Docket for Case No: 11-001510