” ggy2d/2001 12:37 7275521448 AHCA PAGE 62 a, STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner vs. AHCA NO: 05-01-0209-NH HEALTH CARE & RETIREMENT CORPORATION d/b/a JACARANDA MANOR, Respondent. ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the Agency for Health Care Administration (herejnafter referred to as the “Agency") intends to impose a civil penalty in the amount of $2,000.00 upon Health Care & Retirement Corporation d/b/a Jacaranda Manor (hereinafter referred to as "Respondent"). As grounds for the imposition of this civil penalty, the Agency alleges as follows: (1) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. (2) Respondent is licensed to operate as a Nursing Home at 4250 66°" Street North, St. Petersburg, Florida 33709 in Ob . 08/23/2001 12:37 7275521448 AHCA PAGE 6&3 compliance with Chapter 400, Part II, Florida Statutes, and Chapter S9A-4, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400, Part II, Florida Statutes, and provisions of Chapter 59A-4, Florida Administrative Code. Specifically, during the annual licensure survey on June 20, 2001, the Respondent was cited for the following Class III deficiencies: (a) The Respondent failed to ensure that residents were cared for in an environment that maintained their dignity and respect, Specifically, two (2) residents were observed from the hallway lying in bed partially clothed and exposed to full public view. This is a violation of Rule 59B-4,1288, Florida Administrative Code, and Section 400.022(1) (m), Florida Statutes, for which a fine is authorized under Sections 400.022(3), 400.102, 400.121, and 400.23(8)(c), Florida Statutes. Class III deficiency. Fine: $1,000.00. (b) The Respondent failed to provide medically related social services to residents to maintain their highest practicable physical well-being. Specifically, the facility failed to provide needed dental services for one resident. . This is a violation of Rule 59A-4,1288, Florida Administrative Code, and Section 400.022(1) (1), Florida Statutes, for which a " ge/23/2001 12:37 © 7278521448 AHOA _ PAGE 84 fine is authorized under Sections 400.022(3), 400.102, 400.121, and 400.23(8)(c), Florida Statutes. Class fIT deficiency. Fine: $1,000.00. (4) The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 409.23, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules and i regulations for the operation of a nursing home. (5) Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. (6) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. Chapter 59-1, Part II, Florida Administrative Code, constitutes the Agency's procedural rules for administrative proceedings resulting from this complaint. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, your request for an ad saan “98/25/2001 12:37 7275521440 _— AHCA PAGE 85 administrative hearing must conform to the requirements in Rule 28~106, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to dispute material issues of fact in your request for a hearing may be treated by the Agency as an election by you of an informal proceeding under Section 120.57(2), Plorida Statutes. All requests for hearing shall be made to the Agency for Health Care Administration, Attention: Michael P. Sasso, Senior Attorney, 525 Mirrer Lake Drive North, Room 310G, St. Petersburg, Florida 33701. (7) RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST 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. tr HEREBY CERTIFY that a true copy was sent by U.S. Certified Mail, Return “Receipt (2 170 “AAG 492) to Cc, T ; Corporati Sy Agent for Health Care & “Retirement Corporation, 1200 5S. Pine Island Road, _ Plantation, Florida. 33324, and Alma M. Hirsch, Aministrator, Jacaranda eProp ene ° 08/23/2081 12:37 7275521448 AHCA PAGE 86 Manor, 4250 66 Street North, St. Petersburg, Florida 33709, on this, the 3 day of August, 2001. Diet Lager PAT REID-CAU, Field Office Manager Agency for Health Care Administration Division of Managed Care and Health Quality Copies furnished to: Michael P. Sasso, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 3106 St. Petersburg, Florida 33701-3219 Nursing Home Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area 5/6 Office Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 410 Alachua, Florida 33701-3219 Finance & Accountin Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308

Docket for Case No: 01-003616

Orders for Case No: 01-003616