STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Case Nos. 2018008401 Petitioner, Facility Type: Assisted Living GV NEW PORT RICHEY, LLC d/b/a GRAND VILLA OF NEW PORT RICHEY, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (‘the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, GV New Port Richey, LLC d/b/a Grand Villa of New Port Richey (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2017), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose administrative fines in the amount of five thousand dollars ($5,000.00) and a survey fee of five hundred dollars ($500.00) for a total assessment of five thousand five hundred dollars ($5,500.00) based upon one (1) Class II deficient practice. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part IJ, and 429, Part 1, Florida Statutes (2017). 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 facilities and enforcement of all applicable federal regulations, 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, respectively. 4. Respondent operates a one hundred twenty-six (126) bed assisted living facility located at 6120 Congress Street, New Port Richey, Florida 34652, and is licensed as an assisted living facility, license number 4832. 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 Florida law provides: (7) MEDICATION LABELING AND ORDERS. (a) The facility may not store prescription drugs for self-administration, assistance with self-administration, or administration unless they are 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. The identification of each medicinal drug in the container. (b) Except with respect to the use of pill organizers as described in subsection (2), no individual other than a pharmacist may transfer medications from one storage container to another. (c) If the directions for use are “as needed” or “as directed,” the health care provider must be contacted and requested to provide revised instructions. For an “as needed” prescription, the circumstances under which it would be appropriate for the resident to request the medication and any limitations must be specified; for example, “as needed for pain, not to exceed 4 tablets per day.” The revised instructions, including the date they were obtained from the health care provider and the signature of the staff who obtained them, must be noted in the medication record, or a revised label must be obtained from the pharmacist. (d) Any change in directions for use of a medication that the facility is administering or providing assistance with self-administration must be accompanied by a written, faxes, or electronic copy of a medication order issued and signed by the resident’s health care provider. The new directions must promptly be recorded in the resident’s medication observation record. The facility may then obtain a revised label from the pharmacist or place an “alert” label on the medication container that directs staff to examine the revised directions for use in the medication observation record. (e) A nurse may take a medication order by telephone. Such order must be promptly documented in the resident’s medication observation record. The facility must obtain a written medication order from the health care provider within 10 working days. A faxed or electronic copy of a signed order is acceptable. (f) The facility must 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. (g) Pursuant to section 465.0276(5), F.S., and rule 61N-1.006, F.A.C., sample or complimentary prescription drugs that are dispensed by a health care provider, must be kept in their original manufacturer’s packaging, which must include the practitioner’s name, the resident’s name for whom they were dispensed, and the date they were dispensed. If the sample or complimentary prescription drugs are not dispensed in the manufacturer’s labeled package, they must be kept in a container that bears a label containing the following: 1. Practitioner’s name, 2. Resident’s name, 3. Date dispensed, 4. Name and strength of the drug, 5. Directions for use; and, 6. Expiration date. (h) Pursuant to section 465.0276(2)(c), F.S., before dispensing any sample or complimentary prescription drug, the resident’s health care provider must provide the resident with a written prescription, or a faxed or electronic copy of such order. Rule 58A-5.0185(7), Florida Administrative Code. 8. That on May 22, 2018, the Agency completed a complaint survey, Complaint Numbers 2018005405 and 2018007140, of Respondent’s facility. 9. That based upon the review of records, observation, and interview, Respondent failed to ensure that it made every reasonable effort to ensure that resident prescriptions for residents who receive assistance with self-administration of medications are filled or re-filled in a timely manner, the same being contrary to the mandates of law. 10. That Petitioner’s representative reviewed the medication observation records for resident number one (1) on May 22, 2018 and noted the following prescribed medications were not provided to the resident: a. b. c. Amlodipine Besylate 10 mg — Not provided April 2 through 7, 2018. Carvedilol 12.5 mg - Not provided April 2 through 7, 2018. Hydrochlorothiazide 25 mg - Not provided April 2 through 7, 2018. Lovastatin 10 mg - Not provided April 2 through 7, 2018. Omeprazole DR 40 mg - Not provided April 2 through 7, 2018. Hydralazine 50 mg - Not provided April 1 through 7, 2018. Probiotic Formula Cap - Not provided April 2 through 7, 2018. Acetaminophen 325 mg - Not provided April 1 through 7, 2018. Metformin Hel 500 mg - Not provided April 1 through 7, 2018. Aspirin Ec 81 mg - Not provided April 2 through 7, 2018. k. 1. Vitamin B-12 1,000 Mcg - Not provided April 2 through 7, 2018. Oyster Shell Calcitum-Vit D - Not provided April 2 through 7, 2018. m. Meloxicam 15 mg - Not provided April 2 through 7, 2018. 11. That the 2014 Lippincott’s Pocket Drug Guide for Nurses explains the intended use for some of the medications listed above as follows: a e. f. Amlodipine Besylate is prescribed to treat high blood pressure by relaxing blood vessels and improving blood flow. Carvedilol is prescribed to treat high blood pressure and heart failure and is used after a heart attack to improve the chance of survival. Hydrochlorothiazide is prescribed to treat fluid retention and high blood pressure. Lovastatin is prescribed to lower cholesterol to reduce the risk of cardiovascular disease. Hydralazine is prescribed to treat high blood pressure. Aspirin Ec is prescribed for heart health. 12. That Petitioner’s representative reviewed Respondent’s records related to resident one (1) during the survey and noted as follows: a. b. Emergency medical services were called on April 7, 2018. At 11:20 a.m. on April 7, 2018 emergency medical services assessed the resident and sent the resident to a hospital. A note of April 10, 2018 documented the resident was admitted to the hospital with exacerbated Chronic Obstructive Disease (COPD) and NSTEMI a medical term indicating a heart attack 13. That hospital records dated April 7, 2018 document that resident number one (1) was discharged with a diagnosis of NSTEMI (heart attack). 14.‘ That Petitioner’s representative reviewed the medication observation records for resident number six (6) on May 22, 2018 and noted the following prescribed medications were not provided to the resident: a. Rena-Vite Tablet - Not provided April 2 through 6 and April 12, 2018. b. Citalopram 10 mg - Not provided April 2 through 6 and April 12, 2018. c. Atorvastatin 20 mg - Not provided April 1 through 5 and April 11, 2018. d. Melatonin 3 mg - Not provided April 1 through 5 and April 11, 2018. e. Trazadone 50 mg - Not provided April 1 through 5 and April 11, 2018. f. Metroprolol Succ ER 25 - Not provided April 1 and April 3, 2018. g. Doxycycline 100 mg - Not provided April 4, 2018. 15. That Petitioner’s representative reviewed Respondent’s policy and procedure entitled No Pass Policy and Procedure for Medications, dated January 2016, and noted under the section Procedure, Medication Not available: a. The resident care supervisor, memory care supervisor, or shift coordinator must follow up on status of the medication order to ensure resident receives timely. b. If the medication is not received within three (3) days, the physician must be notified. 16. That Petitioner’s representative interviewed Respondent’s staff member “B” on May 22, 108 at 10:37 a.m. who indicated that if a resident is without medication, the director of nursing or administrator is notified to get an emergency medication supply for at least seven (7) days. 17. That Petitioner’s representative interviewed Respondent’s staff member “A” on May 22, 108 at 11:00 a.m. who indicated that if a resident runs out of medication, the doctor is made aware and the facility gets the pharmacy to send a seven (7) day supply. 18. That Petitioner’s representative telephonically interviewed the office manager for the primary care physician for resident number one (1) on May 22, 108 at 3:58 p.m. who indicated that the office reviewed its physician communication records and could locate no communication from Respondent indicating resident number one (1) had not received the resident’s prescribed medications during the period April 2 through 7, 2018. 19. That Petitioner’s representative telephonically interviewed the advanced registered nurse practitioner that worked for the primary care physician for resident number one (1) who indicated that the physician’s office was not notified that resident number one (1) had run out of prescribed medications on April 2, 2018. 20. That Petitioner’s representative interviewed Respondent’s resident care supervisor on May 22, 108 at 4:41 p.m. who indicated that the Respondent facility should have obtained the medication of resident number one (1) and that they were not given approval to order an emergency supply of the resident’s medications. 21. That Petitioner’s representative conducted an exit interview with Respondent’s regional director of operations on May 22, 2018 at 6:05 p.m. who, when informed of the finding that Respondent had failed to take every reasonable effort to timely fill or re-fill prescriptions for residents numbered one (1) and six (6), acknowledged that Respondent was responsible for obtaining the medications and should have purchased medications for the identified residents. 22. That the above reflects Respondent’s failure to take every reasonable effort to timely fill or re-fill prescriptions for residents. 23. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class | violations. 24. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2017). 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 § 429.19(2)(b), Florida Statutes (2017). COUNT II 25. | The Agency re-alleges and incorporates paragraphs (1) through (5) and Count I of this complaint as if fully set forth herein. 26. That pursuant to Section 429.19(7), Florida Statutes (2017), 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 (2017), to verify the correction of the violations. 27. That Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2017). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Florida Statutes (2017). Respectfully submitted this 22™ day of June, 2018. wale Burson Nicola L. C. Brown, Esq. Fla. Bar. No. 0492507 Agency for Health Care Administration 525 Mirror Lake Drive N., 330H St. Petersburg, FL 33701 727.552.1946 (office) Nicola.Brown@ahca.myflorida.com NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. 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. 7013 2250 0001 4950 4360 on June 22, 2018, to Dawn Grady, Administrator, GV New Port Richey, LLC d/b/a Grand Villa of New Port Richey, 6120 Congress Street, New Port Richey, Florida 34652 and by Regular U.S. Mail to Timothy R, Barnes, Registered Agent for GV New Port Richey, LLC, 13770 58" Street North, Suite 312, Clearwater, Florida 33760. Nicola L. C. Brown, Esq. Fla. Bar. No. 0492507 Agency for Health Care Administration 525 Mirror Lake Drive N., 330H St. Petersburg, FL 33701 727.552.1946 (office) Nicola.Brown@ahca.myflorida.com Copy furnished to: Patricia R. Caufman Field Office Manager 10 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: GV NEW PORT RICHEY, LLC d/b/a AHCA No. 2018008401 GRAND VILLA OF NEW PORT RICHEY ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. The Election of Rights form may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you received the Administrative Complaint. If your Election of Rights form with your selected option (or request for hearing) is not timely received by the Agency Clerk, the right to an administrative hearing to contest the proposed agency action will be waived and an adverse Final Order will be issued. In addition, please send a copy of this form to the attorney of record who issued the Administrative Complaint. (Please use this form unless you, your attorney or your qualified representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) The address for the Agency Clerk is: Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I waive the right to a hearing to contest the allegations of fact and conclusions of law contained in the Administrative Complaint. | 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 fine, sanction or other agency action. OPTION TWO (2) I admit the allegations of fact contained in the Administrative Complaint, but I wish to be heard at an informal hearing (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, sanction or other agency action should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. 11 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 agency 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. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number, and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (Optional) I hereby certify that 1 am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: USPS Tracking: Tracking FAQs Track Another Package + Remove Tracking Number: 70132250000149504360 Your item was delivered to an individual at the address at 12:09 pm on June 25, 2018 in NEW PORT RICHEY, FL 34653. Status Delivered June 25, 2018 at 12:09 pm Delivered, Left with Individual NEW PORT RICHEY, FL 34653

Docket for Case No: 18-006678

Orders for Case No: 18-006678