Losils so spk STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case Nos.: 2011013706 vs. ; 2011013707 ANDRADA SUNSHINE CORPORATION d/b/a GOOD SAMARITAN RETIREMENT HOME, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency For Health Care Administration (the ‘“Agency”) and files this administrative complaint against Andrada Sunshine Corporation d/b/a. Good Samaritan Retirement Home, (“Respondent” or “Respondent Facility”), pursuant to §§ 120,569, and 120.57, Fla. Stat., and alleges: NATURE OF—THE-ACTION This is an action to impose an administrative fine in the amount of eleven thousand dollars ($11,000.00) and for such other relief as this tribunal may determine, including a survey fee pursuant ‘to. Section 429.19(7), Florida Statutes, in, addition to any administrative fines imposed, based upon one (1) class I deficiency and six (6) class II deficiencies, pursuant to Chapters 408, Part II, and 429, Part I, Fla. Stat. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections Page 1 of 28 Filed March 13, 2012 10:51 AM Division of Administrative Hearings Qo sO facts ncatuah stile 20.42, 120.60, and 429.07, and Chapters 408, Part II, and 429, Part I, Florida Statutes. ~ 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207, 4 PARTIES 3. The Agency licenses all assisted living facilities and | enforces all applicable Florida statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 65~-bed assisted Living facility located at 507 $.B. 1st Avenue, Williston, Florida 32696, and is | ; licensed as an assisted living facility, license number 25, _5. At all times material to this complaint, Respondent was licensed by the Agency and was required to comply with all 4+_____applicable—rules—and-statutes-+ : ‘ COUNT YT A025 6. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 7. Rule 58A-5.0182, Florida Administrative Code, . requires: 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: Page 2 of 28 (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (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. (c)’ General awareness of the resident's whereabouts. The resident may travel 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 subsection 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. (3) ARRANGEMENT FOR HEALTH CARE. In order to facilitate résident 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—transportatton-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. 8, On November 30 and December 1, 2011, the Agency conducted a complaint investigation survey of the Respondent. 9. Based on the Agency’s surveyor’s interviews, review of Respondent's records and observations, the Agency concluded that the Respondent failed to meet the medical needs of one resident, Resident #1, of the two residents whose care was reviewed by the Page 3 of 28 Agency's surveyor. 10. On November 30, 2011, at 1:00 p.m., the Agency’s surveyor conducted an interview with Respondent's administrator, Respondent’s administrator stated that no podiatrist is scheduled to come to the facility. Residents have not been seen by a podiatrist in an unknown amount of time. li. The Agency’s surveyor’s review of Respondent’s records for Resident #1 revealed that Resident #1 was seen by her physician on 7-18-2011 and again on 11-14-2011, and an order was given each time for Resident #1 to be seen by a podiatrist within a week and for blood pressure monitoring. ; 12. However, Respondent did not assist Resident #1 an making an appointment until a third order was received. A referral on 12~6-2011 to a podiatrist was made by a member of Respondent’s_staff—for _Resident—#1-after-Resident #1"S physician gave a third order on 11-21-2011. 13. Respondent had no documentation for blood pressure monitoring for Resident #1’s blood pressure for the last six months prior to the Agency's survey of November 30 and December 1, 2011. 14, The Agency’s surveyor, who is a Registered Nurse, observed Resident #1 on 11-30-2011 at 1:30 PM. Resident's right great toe was red and swollen; the toenail appeared to be lifting away from the nail bed. Page 4 of 28 15. On 11-30-2011 at 1:30 PM, the Agency's surveyor | interviewed Resident #1. Resident #1 stated that she had not been seen by a podiatrist, and that she has been having pain in her toe for several months. 16. The Agency determined that the’ Respondent’s above-— described failure to provide care and services appropriate to the needs of Resident #1 is a violation of law and describes conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be a class II violation for the purposes of sections 408.813, 408.815, 429,14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative dot. te fine—in the anount—of-$1,000-00—-against Respondent, an assisted * living facility in the State of Florida, for the above-described class II violations, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. . COUNT IT A027 17. The Agency re-alleges and incorporates paragraphs 1 through 5, 10, 11, and 14, as if fully set forth in this count. 18. Rule 58A-5.0182(3), Florida Administrative Rules, requires: Page 5 of 28 saul mY / . ay ‘An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (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. 19. On December 1, 2011, the Agency conducted a complaint investigation survey of the Respondent. 20. Based on the Agency’s surveyor’s interviews, review of Respondent’s records and observations, the Agency concluded that the Respondent failed to timely assist one resident, Resident #1, in _making_an_appointment—with—a—podiatrist ——Tthe—Ageney/s surveyor reviewed Respondent’s care and services provided to two of Respondent’s residents. 21. The Agency’s surveyor interviewed Resident #1 on 11- 30-2011 at 1:30 PM. Resident #1 told the Agency’s surveyor that she has not been seen by a podiatrist. She has been having pain and infections in her toe for several months. 22. The Agency determined that Respondent’s failure to timely assist Resident #1 in making an appointment with a podiatrist was a conditions or occurrences related to the Page 6 of 28 cit on operation and maintenance of a provider ox to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429,19, Florida Statutes. 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, for the above-déscribed class II violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT III A052 23. . The Agency re-alleges and: incorporates paragraphs 1 through—5.,.asiffully_set—forth—inthis—count. 24, Section 429.256, Florida Statutes, requires: (2) Residents who are capable of self-administering their own medications without assistance shall be encouraged and: allowed to do so. However, an unlicensed person may, consistent with a dispensed prescription’s label or the package directions of an over-the-counter medication, assist a resident whose condition is medically stable with the self-administration of routine, regularly scheduled medications. that are intended to be self-administered. Assistance with self- medication by an unlicensed person may occur only upon a documented request by, and the written informed consent of, a resident or the resident's surrogate, guardian, or attorney in fact. For the purposes of this section, self-administered medications include both legend and over-the-counter oral dosage forms, topical i Page 7 of 28 TORI Oe UPTON TOV Oe dosage forms and topical ophthalmic, otic, and nasal dosage forms including solutions, suspensions, sprays, * and inhalers. (3) Assistance with self-administration of medication includes: (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, (c) Placing an oral dosage in the resident's hand or placing the dosage in another container and helping the resident by lifting the container to his or her mouth. (d) Applying topical medications. (e) Returning the medication container to proper storage, : (f) Keeping a- record of when a resident: receives assistance with self-administration under this section, (4) Assistance with self-administration does not include: (a) Mixing, compounding, converting, or calculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet ‘or crushing a tablet as prescribed. (b) The preparation of syringes for injection or the administration of medications by any injectable route. {c) Administration of medications through—intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube inserted in a cavity of the body. (e) Administration of parenteral preparations. (f) Irrigations or debriding agents used in the treatment of a skin condition. (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be given “as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and at the request of a competent resident. (1) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unlicensed person, Page 8 of 28 25, Rule 58A-5.0185, Florida Administrative Code, requires: (3) ASSISTANCE WITH SELF-ADMINISTRATION. (a) For facilities which provide assistance with self- administered medication, either: a nurse; or an ‘unlicensed staff member, who is at least 18 years old, trained to assist with self-administered medication in accordance with Rule 58A-5. 0191, F.A.C., and able to demonstrate to the administrator the ability to accurately read and interpret a prescription label, must be available to assist residents with self- administered medications in accordance with procedures described in Section 429.256, F.S. (b) Assistance with self-administration of medication includes verbally prompting a resident to take medications as prescribed, retrieving and opening a properly labeled medication container, and providing assistance as specified in Section 429. 256(3), F.S. In order to facilitate assistance with self- administration, staff may prepare and make available such items as water, juice, cups, and spoons. Staff may also return unused doses to the medication container. Medication, which appears to have been contaminated, shall not be returned to the container. (c) Staff shall observe the resident take the medication. Any concerns about the resident’s reaction to the medication shall_be_reportedto—the—resi-dent4s health care provider and documented in the resident's record. (d) When a resident who receives assistance with medication is away from the facility and from facility staff, the following options are available to enable the resident to take medication as prescribed: 1, The health care provider may prescribe a medication schedule which coincides with the resident's presence in the facility; 2. The medication container may be given to the resident or a friend or family member upon leaving the facility, with this fact noted in the resident's medication record; 3. The medication may be transferred to a pill organizer pursuant to the requirements of subsection (2), and given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record; or Page 9 of 28 4, Medications may be separately prescribed and dispensed in an easier to use form, such as unit dose packaging; , (e) Pursuant to Section 429.256(4) (h), F.S., the term “competent resident” means that the resident is cognizant of when a medication is required and understands the purpose for taking the medication. (£) Pursuant to Section 429.256(4) (i), F.S., the terms “judgment” and “discretion” mean interpreting vital signs and evaluating or assessing a resident's condition. (5) MEDICATION RECORDS. (a)... . (o) 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 namé 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. 26, Rule 58A-5.024, Florida. Administrati-ve--Code;—require (3) RESIDENT RECORDS. Resident records shall be maintained on the premises and include: (bh) For facilities which manage a pill organizer, assist with self-administration of medications or administer medications for a resident, the required medication records maintained pursuant to Rule 58A- 5.0185, P.A.C. 27. On November 23, 2011, the Agency conducted a complaint investigation survey of the Respondent. 28. Based on the Agency's surveyor’s observations, reviews of Respondent’s records, and interviews, the Agency determined Page 10 of 28 ete O) a that the Respondent failed to provide each resident with medication as ordered by each resident’s physician and failed-to properly assist residents with self-administration of medication. 29, The Agency’s surveyor’s review of Respondent’s records for Resident #11 revealed that Resident #11 was prescribed Gabapentin 400 milligrams (mg) capsules, with instructions to take 1 capsule 4 times a day for nerve pain. 29.a, The Gabapétin was noted as discontinued on Respondent's October 2011 medication observation record ("MOR”) for Resident #1l. 29,b. However, Respondent’s records for Resident #11 contained a Physician's order, date unknown, changing the medication to Gabapentin 300 mg capsule, with instructions to take 2 capsules by_mouth_3_times.a_day. 29.c, Respondent’s records contained no order discontinuing either dosage of Gabapentin medication. 29.d. Yet, according to the MOR, Resident #11 did not receive Gabapentin 300 mg capsule per physician's order for 20 days, from 11/1/2011 through 11-20-2011. 29.¢@. Respondent’s records for Resident #11. contained a new order dated 11-21-2011 for Gabapentin 300 mg, with instruction to take one capsule by mouth every 8 hours, initiated on 11-21-2011. Page 11 of 28 oa “) 29.£. The Agency's surveyor’s review of the October and November 2011 MOR's for Resident #11 also revealed that Temazepam 30 mg, with instructions to take one tablet at bedtime as needed for sleep per physician's order, was instead given twice on 11/8/2011 in error. 30. On 11-23-2011 at 3:45 PM, the Agency’s surveyor interviewed Resident #11. Resident #11 stated that she has been out. of her Hydrocodone medication for about 2 weeks. She was told by members of Respondent’s staff that there was none in the medication cart, and she had to wait until the 30th of November to have it filled through the Veteran's Affairs pharmacy. Resident #11 stated to the Agency's surveyor that she is not sure why there is no Hydrocodone left since she only takes it for “break-through” pain, and there should have been enough left Lo last her until the 30th, Resi-dent—#141—stated-that ‘she was in a lot of pain and very upset when she first found out there was no Hydrocodone available for her. . 31. The Agency’s surveyor’s review of the MOR for Resident #11 revealed that Resident #11 received Hydrocodone/APAP 5/500 mg on 11-19-2011 and 11~21-2011, However, Resident #11 told the Agency’s surveyor that she did not receive any Hydrocodone on 11-19-2011 and 11-21-2011. 32. The Agency’s surveyor’ s observation of the contents of Respondent’s medication cart on 11-23-2011 at 2:15 PM revealed Page 12 of 28 that no Hydrocodone/APAP 5/500 mg was available for Resident #11. 33. On 11-23-2011 at 12 noon, the Agency’s surveyor observed Respondent’s medication assistance/administration by one of Respondent’s Medical Technicians ("Med Tech”) . The Agency’s surveyor observed that a medication tablet was place into a medication cup at the medication cart, in the hallway and away from the resident. The medication cup was given to Resident #1, who was sitting at a table in the dining room. The Med Tech walked away from Resident #1 without explaining what medication was to be taken. The Med Tech also did not observe Resident #1 taking the medication. 34. As the Agency’s surveyor continued to further observe and review Respondent’s 12 noon medication assistance/administratiion by _Med_Tech,—on—1.-23-20-11,—the Agency's surveyor observed that 8 residents did not receive 11 medication as ordered on 11-23-2011: 34.a. Resident #13 did not receive Tylenol ER 650 mg 1 tablet at 1:00 PM, and Mycostatin Powder was not applied topically to abdomen at 12 noon. 34.b. Resident #14 did not receive Simethicone 80 mg 1 chew tablet at 1:00 PM. 34.c. Resident #15 did not receive Tylenol 500 mg 1 tablet at 12 noon. Page 13 of 28 = 34.d. Resident. #16 did not ‘tablets at 2:00 PM. 34.e. Resident #17 did not tablet at 1:00 PM. . 34.f. Resident #18 did not tablet at 1:00 PM. 34.g. Resident #12 did not tablet at 12 noon. 34.h. “Resident #19 did not milliliters (ml) at 12 noon. receive Tylenol 500 mg 2 receive Tylenol 500 mg 1 receive Tylenol ER 650 mg 1 receive Buspar 10 mg 1 receive Guaifenesin 100 mg/5 35. The Agency’s surveyor’s review of Respondent’s narcotics log, controlled substance count discrepancies as follows: count, revealed medication 35.a. Hydrocodone/APAP count on hand = 18; sign out 35.b. Lyrica count on hand 35.¢. Ativan count on hand 36. On 11-23-2011 at 1:30 PM, interviewed Med Tech. The Agency’s = 6: sign out sheet = 15 = 52; sign out sheet = 53 the Agency’s surveyor surveyor was told that Med Tech has been working at this facility for approximately 2 weeks, and he does not know the residents by name. Med Tech stated that he gives out the medications to the residents without supervision. Med Tech stated he is aware of the discrepancies in the controlled substance medication counts, but Page 14 of 28 wileimmnss does not know how they happened. Med Tech stated he did not count the controlled substance medications that morning when he first arrived for his shift, because there is no medication technician working during the night shift. 37. ° On 11-23-2011 at 2:00 PM, a second Agency Surveyor observed that Med Tech appeared very confused by routine questions ‘asked in a clear, straight-forward manner. Med Tech did not appear to understand where controlled substance . medications were stored until directed by Respondent's Administrator. Med Tech appeared confused by what and where the medication is which he was asked to locate, Respondent’s Administrator was constantly stepping forward to show him medications and converse with him in another language. Respondent’s Noon Medication Assistance was completed at 2:20 PM. 38. The Agency’s surveyor’s review of the Medication Observation Record (“MOR”) for Resident #18 revealed that BD Insulin U100 % milliliter (ml), “use as directed,” and Lantus 100U/ml inject 13 units subcutaneous every day, are being administered, injected, by a Medication Technician, not a nurse, and the MOR is signed by an unknown member of Respondent’s staff. Page 15 of 28 siniinancksstiliec c) oy 39. In an interview on 11-23-2011 at 3:05 pm with resident #9, the Agency’s surveyor was told, "My insulin injections are done by the head guy." 40. The “head guy” was identified to the Agency’s surveyor as being the owner of Respondent, who is a Registered Nurse. 41. Respondent's failure to provide each resident with medication as ordered by each resident’s physician and failure _to properly assist each resident with self-administration of ‘ medication are conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the Agency has determined present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm will result from Respondent's failures, a Class I violation, pursuant to § 408.813, Florida Statutes. 42. On November 30 and December 1, 2011, the Agency conducted another complaint investigation survey of the Respondent. 43. Based on the Agency’s surveyor’s interviews and review of Respondent’s records, the Agency determined that the Respondent failed to observe one resident, Resident #2, during assistance with medication, of the two residents whose care was reviewed by the Agency’s surveyor. Respondent's failure Page 16 of 28 sesh Mee resulted in Resident #2 carrying nine (9) medications in his wallet. 44, When interviewed on 12-01-2011 at 11:00 am, Respondent’s administrator told the Agency surveyor that he is not aware of any resident not taking medication as ordered. Respondent's administrator stated that he is aware that Resident #2 had behavior problems in the past, but he has been fine lately. 45. Respondent’s records for Resident #2 reveal that Resident #2 was admitted to the facility on 9-19-2006. '46. Respondent’ s Medication Observation Record (“MOR”) for Resident #2 has been initialed to indicate that all medications during October 2011 and November 2011 had been taken by Resident #2. 47. Respondent’s Resident Observation Log note dated 8-18- 2011 noted that Resident #2's case worker reported that Resident #2 showed her several pills that Resident #2 had not taken. Resident #2 claimed the pills were rat poison, and that the President of the United States asked Respondent's staff to poison him. Resident #2's physician was noted to be aware of Resident #2's behavior. No documentation was noted for a psychiatric evaluation of Resident #2. Resident Observation Log note dated 9-12-2011 revealed that Resident #2 was taking his Page 17 of 28. jake 0) -) medication one at a time, and that Respondent’s staff had been watching him while he took his medication. 48. On 12-01-2011 at 12:30 PM, the ‘Agency’s surveyor interviewed Resident #2. Resident #2 stated that he feels safe at this time but it depends who is giving out medications. Resident #2 believes that staff had been trying to poison him, and that the President was telling Respondent’s staff to poison him. Resident #2 showed the Agency’s surveyor that he had nine (9) pills in his wallet “to prove that they are poison.” Resident #2 took the pills out of his wallet. The pills were identified and destroyed. 49. The Agency determined that Respondent’s failure to have and maintain a complete and accurate medication administration record for each resident receiving medications and’ to observe each resident during self=administration—are conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $6,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described Page 18 of 28 Ao ree ‘class I and II violations, pursuant: to Chapters 408, Part It, and 429, Part I, Plorida Statutes, or such further relief as this tribunal deems just. COUNT IV A054 50. The Agency re-alleges and incorporates paragraphs 1 through 5 and 24 through 40, as if fully set forth in this count. 51. On November 23, 2011,. the Agency conducted a complaint investigation survey of the Respondent. 52. Based on the Agency’ s surveyor’s review of Respondent’s records and on interviews, the Agency determined that the Respondent failed to accurately document each Resident’s Medication Observation Record. 53. The Agency determined that Respondent’s failure to accurately document each resident's Medication—Observation Record is a condition or occurrence related to the operation and . Maintenance of a provider or to the care of residents which the agency determined directly threatens the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. 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 Plorida, for the above-described Page 19 of 28 2 _ y class I and II violations, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT V_ A055 54. The Agency re-alleges and incorporates paragraphs 1 through 5 and 24 through 26, as if fully set forth in this count. 55. Rule 58A-5.0185(6), Florida Administrative Code, requires: (6) MEDICATION STORAGE AND DISPOSAL. (a) In order to accommodate the needs and preferences of residents and to encourage. residents to remain as independent as possible, residents may keep their medications, both prescription and over-the-counter, in their possession both on or off the facility premises; or in their rooms or apartments, which must be kept locked when residents are absent, unless the medication is in a secure place within the rooms or apartments or in some other secure place which is out of sight of other residents, However, both prescript.ion.and_over-= the-counter medications for residents shall be centrally stored if: 1. The facility administers the medication; 2. The resident requests central storage. The facility shall maintain a list of all medications being stored pursuant to such a request; 3. The medication is determined and documented by the health care provider to be hazardous if kept in the personal possession of the person for whom it is _ prescribed; 4. The resident fails to maintain the medication in a safe manner as described in this paragraph; 5. The facility determines that because of physical arrangements and the conditions or habits of residents, the personal possession of medication by a resident poses a safety hazard to other residents; or 6. The facility’s rules and regulations reguire central storage of medication and that policy has been provided Page 20 of 28 to the resident prior to admission as required under Rule 58A-5.0181, F.A.c. (b) Centrally stored medications must be: 1. Kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times; 2. Located in an area free of dampness and abnormal temperature, except that a medication requiring wefrigeration 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. (c) Medication which has been discontinued but which | has not expired shall be returned to the resident or the resident’s representative, as appropriate, or may be centrally stored by the facility for future resident use by the resident at the resident’s request. If centrally stored by the facility, it shall be stored separately from medication in current use, and the area in which it is stored shall be marked “discontinued “medication.” Such medication may be reused if re- prescribed by the resident’s health care promider. oh ee (d) When a resident's stay in the facility has ended, the administrator shall return all medications to the resident, the resident’s family, or the resident’s guardian unless otherwise prohibited by law. If, after notification and waiting at least 15 days, the resident’s medications are still at the facility, the medications shall be considered abandoned and may disposed of in accordance with paragraph (e). . (e) Medications which have been abandoned or which have expired must be disposed of within 30 days of being determined abandoned or expired and disposition shall be documented in the resident’s record. The medication may be taken to a pharmacist for disposal or may be destroyed by the administrator or designee with one witness. (f) Facilities that hold a Special-ALF permit issued by the Board of Pharmacy may return dispensed medicinal drugs to the dispensing pharmacy pursuant to Rule Page 21 of 28 cee ecnserinieernte slarsldanedatase 7 2) i 64B16-28.870, F.A.C. 56. On November 30 and December 1, 2011, the Agency conducted a complaint investigation survey of the Respondent. 57. Based on the Agency’s surveyor’s review of ’ Respondent's records and on interviews, the Agency determined that the Respondent failed failed to secure residents' ' medications contained in the Respondent facility's medication cart. . 58. On 11-30-2011 at 9:15 am, the Agency’s surveyor conducted a tour of the Respondent’s facility with Respondent’ s administrator. The Agency's surveyor observed an unlocked and unattended medication cart in the hallway outside the dining room. | 59. On 11-30-2011 at 9:45 am, the Agency’s surveyor conducted an interview with Respondent’s Medication Technician, “Med Tech,” and Respondent’s administrator. Med Tech stated he forgot to lock the med cart before walking away from it because he is very tired since he works a night shift at another facility and was called in to Respondent's facility to cover for someone else. The Agency determined that Respondent's failure to properly centrally store each resident's medications by failing to lock Respondent's medication cart is a condition or occurrence related to the operation and maintenance of a provider or to the Page 22 of 28 9 i: care of residents which the agency determined directly threatens the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429,19, Florida Statutes. 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, for the above-described class II violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. . COUNT VI_A152 60. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 61, Section 429,28(1), Florida Statutes,—gquarantees: (1) 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. . (bo) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. . 62. Rule 58A-5.023, Florida Administrative Code, requires: (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Page 23 of 28 sy , > j Section 429.28(1) (a), F.S.3 and ' 2, Must be maintained free of hazards; and 3. Must ensure that all existing architectural, 4 mechanical, electrical and structural systems and . appurtenances are maintained in good working order. (b) Pursuant to. Section 429.27, F.S., residents shall . be given the option of using their own belongings as | space permits. When’ the facility supplies the ’ furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress a ‘comfortable height to ensure 4 easy access by the resident; | 2. A closet or wardrobe space for hanging clothes; 3. A dresser, chest or other furniture designed for storage of personal effects; 4. A table, bedside lamp or floor lamp, and waste basket; and 5. A comfortable chair, if requested... (c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency. ; ; (d) Residents who use portable bedside commodes must be provided with privacy during use. ; (e) Facilities must make available linens and personal laundry services for residents who require such | services. Linens provided by a facility shall be free ; of tears, stains and _not_be threadhare. —— | 63. On November 30 and December 1, 2011, the Agency conducted a complaint investigation survey of the Respondent. 64. Based on the Agency’s surveyor’s review of Respondent's records, on interviews and on the Agency's surveyor’s observation of Respondent’s Licensed premises, the Agency determined that the Respondent failed to provide a decent and safe environment for residents. 65. On 11-30-2011 at 9:15 am, the Agency's surveyor conducted a tour of Respondent's facility with Respondent’ s Page 24 of 28 Administrator. In addition to an unlocked and unattended medication cart, the Agency’s surveyor observed carpets littered with dust and dirt, dust and dirt visible under residents! beds, A strong odor of mildew and urine was noted in the living room. A seven (7) foot high metal post lamp was noted to be unanchored with a spliced electrical cord. A space heater was noted to be in use and visible from the door of room B-16. Additionally, the Agency's surveyor observed loose hand rails, a shorted-out wall plug in the living room of the secured unit, and a screen door Open to an overgrown breezeway with loose supports for gutters. There was an open wall socket for lights. A wooden board was observed to be nailed down over concrete. A storage door in the breezeway was unlocked. An empty helium tank was being stored in the laundry area, where there was also an open electrical box and_a_large raised cement platform, which increase the—risk—of either a resident or one of Respondent’ s employees falling. 66. On 11-30-2011 at 9:15 am and throughout the Agency’s surveyor’s tour of Respondent’ s facility with Respondent's administrator, the Agency’s surveyor questioned Respondent’ s administrator regarding thé Agency's surveyor’s observations about the poor state of Respondent’s facility. The administrator stated that he is aware of all the physical improvements that are needed in the facility, and he is working on scheduling repairs. He has only been employed four (4) days Page 25 of 28 and is aware there is a lot of work needed to make the facility safe and comfortable for the residents. 67. The Agency’s surveyor’s observation of Respondent’ s facility again on 12-1-2011 at 9:55 am revealed that the facility still had dirt and debris on carpeting, dusty furniture, dust under beds, and a strong odor of urine throughout the facility, but especially strong in the living room area. 68. During an interview on 12-01-2011 at 10:00 am with Respondent’s Administrator, the Agency's surveyor was told that Respondent’ s administrator is aware of the need for cleaning throughout the facility. He has a housekeeper who will be cleaning the facility. 63. The Agency determined that Respondent’s failure to have and to maintain a safe and’ decent physical _environment_for_.§- Respondent’s residents is a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threatens the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted Page 26 of 28 Jive batitl ss i cy “) living facility in the State of Florida, for the above-described class II violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. NOTICE 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 Flection 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, whose telephone number is 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. 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.7003 1010 0001 3600 4668, to Miskel Ortiz, Administrator, 507 S.B. 1** Avenue, Williston, FL 32696, and by regular U.S. Mail to Gus R. Benitez, Esq., as Registered Agent for Andrada Sunshine Corp., 1223 East Concord Street, Orlando, FL 32803, on January af) , 2012. : James H. Harris istant General Counsel Fla. Bar. No. 817775 Agency for Health Care Admin. 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 727-552-1944 (office) 727-552-1440 (facsimile) Page 27 of 28 cnt i ails Copies furnished to: Anna Lopez, HFE Supervisor, Alachua Page 28 of 28 (Miske1 Ortiz, Administra jGood Samaritan Rétirement Home {507 S.E. 1** Avenue Williston, FL 32696 7003 1010 0001 a5 04. OO 4bb8

Docket for Case No: 12-000892