STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2011006061 AHCA No.: 2011006320 Vv. Return Receipt Requested: 7009 0080 0000 0586 2010 SHALOM MANOR RETIREMENT HOME d/b/a SHALOM MANOR, 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 Shalom Manor Retirement Home d/b/a Shalom Manor (hereinafter “Shalom Manor”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2010), and alleges: NATURE OF THE ACTION 1. This is an action to revoke the assisted living facility license [License No.: 5167] of Shalom Manor and to impose an administrative fine of $40,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2010), for the protection of public health, safety and welfare. Filed August 9, 2011 1:39 PM Division of Administrative Hearings JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2010), and Chapter 28-106, Florida Administrative Code (2010). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2010). 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 (2010), and Chapter 58A-5 Florida Administrative Code (2010). 5. Shalom Manor operates a 35-bed assisted living facility located at 2771 N. W. 58% Terrace, Lauderhill, Florida 33313. Shalom Manor is licensed as an assisted living facility under license number 5167. Shalom Manor 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 SHALOM MANOR FAILED TO ENSURE THAT CARE AND SERVICES WERE APPROPRIATE TO EACH RESIDENT’S NEEDS. RULE 58A-5.0182, FLORIDA ADMINISTRATIVE CODE RULE 58A-5.016(8) (a), FLORIDA ADMINISTRATIVE CODE CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. For AHCA No.: 2011006061, Shalom Manor was cited with three (3) Class I deficiencies and four (4) Class II deficiencies as a result of a complaint investigation survey that was conducted on May 16, 2011. 8. For AHCA No.: 2011006320, the Agency entered an Immediate Moratorium on Admissions on June 7, 2011 on the basis that the Agency found that an immediate serious danger to the public’ health, safety, or welfare existed which required such emergency limitation of the license. The Immediate Moratorium on Admissions is based on the facts set out within the Moratorium and within this Administrative Complaint 8. A complaint investigation survey was conducted on May 16, 2011. Based on observations and interviews, it was determined the facility failed to ensure care and services appropriate to each resident's needs were provided, for 3 out of 4 sampled residents (Residents #1, #2, & #3). The findings include the following. RESIDENT #1 9. Resident #1 was examined by an ARNP on 05/10/11. Review of the exam sheet notes a medical diagnosis of HIV, Diabetic, Hypertension, history of seizures, history of falls and abnormal gait. 10. An interview with the Administrator at 12:30 PM on 05/16/11 revealed the facility was not aware of any nursing requirements (accuchecks and/or insulin administration) regarding the resident being a diabetic. 11. It was also revealed the facility had not made any contact attempts to the family or prior physicians to determine if the resident required , accuchecks and/or insulin administration. » 12, The facility failed to have a completed Health Assessment within the required time frame to ensure appropriate care and services are provided with respect to the resident's current medical diagnosis and needs. 10. Record review revealed Resident #1 was found unresponsive in his/her room. 11. The Resident Observation Log dated 05/12/11 at approximately 6 AM noted the following: Arrived at 6 AM made rounds. Went to Resident #1 room he was not calling as usual. Staff called him at least 3 times no response, touched the chair, no response. Called the night staff and accompanied her to Resident #1's room, she called him no response, told her-confirmed that Resident #1 was deceased. 11. Employee #1 went to the office and told the Administrator the resident was deceased. The Administrator went immediately to the room and confirmed, family was notified, police was notified, and funeral arrangements will be made by family. The time of death is not known by staff. Further record review revealed the resident did not have a signed DNR. 12. Interviews with the Administrator and Employee #1 on 05/16/11, during the survey revealed none of the three staff (the Administrator, Employee #1 & #2) that observed Resident #1 unresponsive in the AM performed CPR or called for Emergency Services (911) in a timely manner. RESIDENT #2 13. Resident Observation notes documented resident was found unresponsive at 2:15 AM on 07/24/10 and sent to the hospital 911 as noted in file. However, the file failed to note whether CPR was initiated by staff prior to emergency services arriving at the facility to treat the resident. During an interview with the Administrator at 12:10 PM, she was unable to prove or provide documentation that CPR was initiated by the facility's staff upon finding the resident unresponsive. RESIDENT #3 14, Review of Resident #3's Health Assessment form dated 01/21/11, noted the resident requires assistance with his/her self-administration of medications. According to the Administrator and Employee #2 (the Medication Tech) the resident has not received assistance with medications from the facility since admission. Further interview with the Administrator revealed the facility was unable to provide a physician’s order or an updated health assessment noting the resident did not require any assistance with self-administered medications. 15. The Administrator and the Office Manager/Resident Care Aid (Employee #5) of the facility was interviewed on the day of the survey (during an exit conference) and confirmed the findings. 16. Based on the foregoing facts, Shalom Manor violated Florida Administrative Code, Rule 58A-5.0182 and Rule 58A- 5.016(8) (a), herein classified as a Class I violation pursuant to Section 408.813(1) (a), Florida Statutes, which warrants an assessed fine of $10,000.00 pursuant to Section 429.19(2) (a), Florida Statutes, and gives rise to the revocation of the assisted living facility license pursuant to Section 429.14(1) (e) (1), Florida Statutes. COUNT II SHALOM MANOR FAILED TO ENSURE THAT ALL RESIDENTS ARE FREE OF NEGLECT AND RECEIVE EMERGENCY SERVICES. SECTION 429.28(1) (a) and (j), FLORIDA STATUTES CLASS I VIOLATION 17. AHCA re-alleges and incorporates paragraphs “(1) through (5) as if fully set forth herein. 18. A complaint investigation survey was conducted on May 16, 2011. Based on record review and interview, it was determined the facility failed to ensure that all residents are free of neglect and receive emergency services (care) as needed, for 1 out of 4 sampled residents (Resident #1). The findings include the following. 19. Observation Log dated 05/12/11 at approximately 6 AM revealed the following entry. Arrived at 6 AM made rounds. Went to Resident #1's room, he was not calling as usual. Staff called him at least 3 times no response, touched the chair, no response. Called the night staff and accompanied her to Resident #1's room, she called him no response, told her-confirmed that Resident #1 was deceased. 20. Employee #1 came to the office and told the Administrator the resident was deceased. The Administrator went immediately to the room and confirmed, family was notified, police was notified, and funeral arrangements will be made by family. The time of death is not known by staff. Further record review revealed the resident did not have a signed DNRO. 21. An interview with the Administrator at 11:30 AM on 05/16/11 revealed the notes in Resident #1's file dated 05/12/11 were written by her, after speaking to Employee #1 and Employee #3. It was also revealed that upon her arrival to Resident #1's room, she did not perform CPR or use the AED machine which is located in the office. 22. According to the Administrator she realized he was already dead and just returned to the office and called 911. When questioned regarding the time frame from observation of resident being deceased and notifying 911, she reported only about’ 10 minutes. Through further interview accompanied by the Attorney General's Office investigator, the Administrator finally confirmed that it took longer than 10 minutes in which 911 was notified, but was unable to give exact time. The Administrator also during interview was unable to provide an explanation of why upon responding to Resident 1 and determining the resident was unresponsive that CPR was not performed immediately and 911 called. It was also revealed she was not aware of any life threatening illness of Resident #1. Upon request of a DNRO for the resident, it was revealed the facility did not have a signed DNRO for the resident. 23. An interview with Employee #1, 18t person noted in 8 notes that found resident deceased/first respondent at 11 AM on 05/16/11, confirmed the above events as noted on 05/12/11. It was also revealed that she just touched Resident #1's body, but did not check for a pulse and did not perform CPR once she realized the resident was unresponsive and not breathing. She also confirmed upon arrival of Employee #3 to examine the body that she also did not perform CPR or call 911. 24. Further interview revealed Employee #1 was not able to provide an explanation for the reason she did not follow protocol as the first respondent to an unresponsive person and immediately perform CPR and call 911. It was also revealed she was not aware of any life threatening illness of Resident #1. 25. Review of the Offense Incident Report/Police Report dated 05/12/11 provided by the Police Department, confirmed 911 was not contacted in a timely manner. The Report notes that on 05/12/11 at approximately 0640 hours an officer was dispatched to facility in reference to a deceased person. The report notes the following: The Administrator last saw the resident at 4 AM in room 4G. Resident #1 suffers from HIV, Diabetes, and Seizures. At approximately 5:50 AM staff members Employee #1 & #2 informed her that Resident #1 was deceased. She then saw that Resident #1 was deceased sitting in his/her wheelchair. She then dialed 911 at approximately 6:37 AM. No attempts to perform CPR were administered by her staff. As per Employee #2 stated, she last saw Resident #1 alive on 05/12/11 at approximately 4 ~AM. Resident was sleeping in his bed.- Around 6 AM she was informed by Employee # 1 that Resident #1 was dead. She then saw Resident #1 was not breathing sitting in his/her wheelchair. She then placed a bed sheet over Resident #1's body and notified the Administrator. As per Employee #1, on 05/12/11 at approximately 6 AM she found Resident #1 not breathing in his/her wheelchair. She then notified Employee #2 and the Administrator. 26. The information obtained from the police report, the resident's file and interviews, confirmed that. once Resident #1 was found unresponsive and not breathing the facility waited approximately 47 minutes before calling 911 and during this time’ did not perform. CPR prior to 911 being called nor after 911 called. The facility intentionally failed to perform CPR and deprived Resident #1 of this needed service, as required. 27. Further interview also revealed the Administrator failed to properly investigate a death of a resident at the facility to prevent future reoccurrences and to provide the basis for future training. 28. Based on the foregoing facts, Shalom Manor violated Section 429.28 (1) (a) and (3), Florida Statutes, herein classified as a Class I violation pursuant to Section 408.813(1) (a), Florida Statutes, which warrants an assessed fine of $10,000.00 pursuant to Section 429.19(2) (a), Florida 10 Statutes, and gives rise to the revocation of the assisted living facility license pursuant to Section 429.14(1) (e) (1), Florida Statutes. . COUNT IIT SHALOM MANOR’S ADMINISTRATOR FAILED TO APPROPRIATELY AND ADEQUATELY SUPERVISE AND OPERATE THE FACILITY FOR THE SAFETY AND WELL-BEING OF RESIDENTS. RULE 58A-5.019(1), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS II VIOLATION 29. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 30. A complaint investigation survey was conducted on May 26, 2011. Based on observations, record review, and interview, it was determined the Administrator failed to appropriately and adequately supervise and operate the facility for the safety and well-being of the residents. The findings include the following. 31. The Administrator failed to ensure that all staff is adequately trained in the facility's policy on DNRO, - Advanced Directive and AED to ensure the safety and well-being of all residents. Further interview also revealed that the Administrator failed to properly investigate a death of a resident at the facility to prevent future reoccurrences and to provide the basis for future training. 32. Record review, interview, and observations also 11 confirmed the Administrator failed to ensure the rights of residents to live in a safe and decent living environment free of abuse and neglect was maintained. 33. Throughout the survey conducted on 05/16/11 between the hours of 9:30 AM and 3:45 PM, it was noted the Administrator did not have knowledge of the resident's well-being and constantly relied upon staff in answering various medical questions regarding sampled residents. 34. Based on the foregoing facts, Shalom Manor violated Rule 58A-5.019(1), Florida Administrative Code, herein classified as a Class II violation, pursuant to Section 408.813(2) (b), Florida Statutes which warrants an assessed fine of $2,000.00, pursuant to Section 429.1(2) (b), Florida Statutes. COUNT IV SHALOM MANOR FAILED TO ACCURATELY MAINTAIN MORs (MEDICATION OBSERVATION RECORDS) FOR RESIDENTS. RULE 58A-5.018(5) (b), FLORIDA ADMINISTRATIVE CODE CLASS II VIOLATION 35. AHCA vxre-alleges = and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. A complaint investigation survey was conducted on May 16, 2011. Based on record review and interview, it was determined the facility failed to accurately maintain MORs 12 (medication observation records), for 2 out of 4 sampled residents (Resident #1 & #3). The findings include the following. RESIDENT #1 37. Upon request of Resident #1's MORs for March through May 2011, it was revealed by the Administrator and Employee #2 (Medication Technician), the facility was unable to locate: the prior and current month’s MORs. It was revealed by the Administrator and Employee #2 the facility provided assistance with self-administered medications daily to the resident and documented on the MORs daily. 38. Upon request of current prescribed medications, it was also revealed the facility did not have any documentation of the currently prescribed medications for the resident. According to Employee #2, it was revealed the facility provided assistance with all the resident's medications provided by the Resident's family, but they did not have any documentation of the medications provided by the family or the date provided to the facility. 39. Employee #2 provided several bottles containing multiple pills of resident #1's medication for review, but there were no MOR's reflecting same: Divalproex Sodium, 250 mg tab, _take 1 tablet by mouth daily, dated 12/20/10. Sulfameth/TMP DS take 1 tablet by mouth daily, dated 11/17/10. SMZ-TMP, take 1 13 tablet by mouth daily, dated 12/23/10. Diphen/Atropine, take. 1 tablet 4 times a day as needed, dated 10/27/10. Lisinopril 5 mg, take 1 table daily, dated 3/31/11. Sulfameth DS take by mouth as directed, dated 3/31/11. Phenytoin, take one capsule by mouth three times daily, dated 3/31/11. Glipizide ER 2.5 mg, take 1 tablet by mouth, dated 3/31/11. Labelalol 100 mg, take 1/2 tablet twice daily, dated 3/31/11. RESIDENT #3 40. Upon request of Resident #3's MORs for March through May 2011, it was revealed by the Administrator and Employee #2 (Medication Technician), that the facility did not have current month or prior month MORs for the resident. It was revealed by the Administrator and Employee #2 that the facility does not provide assistance with self-administered medications for the resident. 41. Review of Resident #3's Health Assessment form dated 01/21/11, noted the resident requires assistance with his/her self-administration of medications: According to the Administrator, the resident has not received assistance with medications from the facility since admission on 1/21/11. Further interview with the Administrator revealed the facility was unable to provide a physician’s order or an updated health assessment noting the resident did not require any assistance with self-administered medications. 14 42. Review of discharge instructions from the hospital in the resident's record revealed on 3/13/11 resident #3 had a diagnosis of "Back Sprain", and had prescriptions of Norflex, Toradol, and Vicodin. There was no MORs available for resident #3. 43. Based on the foregoing facts, Shalom Manor violated Rule 58A-5.0185(5) (b), Florida Administrative Code, herein classified as a Class II violation. pursuant to Section 408.813(2) (b), which warrants an assessed fine of $2,000.00, pursuant to Section 429.19(2) (b), Florida Statutes. COUNT V SHALOM MANOR FAILED TO ENSURE A SAFE ENVIRONMENT FREE OF BEDBUGS . RULE 58A-5.023(3) (a), FLORIDA ADMINISTRATIVE CODE CLASS II VIOLATION 44. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 45. A complaint investigation survey was conducted on May 16, 2011. Based on record review and interview, it was determined the facility failed to provide a safe environment free of bedbugs. The findings include the following. 46. An interview with the Administrator at 9:40 AM on 05/16/11 revealed the facility has bedbugs in a few areas of the 15 facility. It was revealed staff found bedbugs in the Common Area/TV room a couple of weeks ago and the pest control exterminator was notified. However, the facility was not able to provide documentation indicating treatment of bedbugs by this pest control company. 47. The facility contacted a new licensed pest control company (certified experts in bedbugs) on 05/16/11 for further evaluation. Review of the pest control report from this evaluation revealed the facility has bedbugs throughout’ the premises and required treatment. 48. A telephone referral was made to the Dept. of Health (DOH) on 5/16/11. On 5/25/11, the DOH inspection report confirmed the presence of bed bugs in several resident rooms. 49, Based on the foregoing facts, Shalom Manor violated Rule 58A-5.023(3) (a), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $2,000.00 and gives rise to the revocation of the assisted living facility license. 16 COUNT VI SHALOM MANOR FAILED TO ENSURE THAT NEW RESIDENTS HAVE A MEDICAL EXAMINATION COMPLETED ON A RESIDENT HEALTH ASSESSMENT FORM WITHIN 30 DAYS OF ADMISSION. RULE 58A-5.0181(2) (b), FLORIDA ADMINISTRATIVE CODE CLASS II VIOLATION 50. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 51. A complaint investigation survey was conducted on May 16, 2011. Based on record review and interview, it was determined the facility failed to ensure new residents admitted to the facility have a medical examination completed on a Resident Health Assessment (form 1823) within 30 days of admission, for 2 out 4 sampled residents (Resident #1 and #2). The findings include the following. 52. Record review revealed Resident #1 was admitted to the facility on 03/16/11, but did not have a completed Resident Health Assessment (ACHA form 1823). An interview with the Administrator at 11 AM on 05/16/11 revealed the facility did not have a Resident Health Assessment form for the resident. According to the Administrator, the facility forgot to remind the in-house physician that Resident #1 was a new admission and needed an exam. 53. It was also revealed by the Administrator the facility 17 had no knowledge or documentation of the resident's current medical history. The facility was also unable to provide documentation that this resident was appropriate for placement in the ALF and the resident's needs could be met in this facility. 54. Further review revealed the resident was not seen by the ARNP until 05/10/11, almost two months after the resident was admitted. The documentation by the ARNP on 5/10/11 revealed resident #1 has diagnosis of Diabetes Mellitus, HIV, Hypertension, History of Seizures and Falls, and Gait abnormality. The ARNP also documented the resident should have "daily oversight". 55. Record review revealed Resident #2 was admitted to facility on 03/19/11, but did not have a completed Health Assessment done until 05/25/11. According to the Administrator the facility did not have another Health Assessment completed within the 30 day required time frame. 56. Based on the foregoing facts, Shalom Manor violated Rule 58A-5.0181(2) (b), Florida Administrative Code, herein classified as a Class [II violation, pursuant to Section 408.813(2) (b), Florida Statutes, and which warrants an assessed fine of $2,000.00 pursuant to Section 429.19(2)(b), Florida Statutes. 18 COUNT VII SHALOM MANOR FAILED TO DISCHARGE A RESIDENT WHO COULD NO LONGER HAVE THEIR IS NEEDS MET AND NO LONGER MET THE CRITERIA FOR CONTINUED RESIDENCY. RULE 58A~5.0181(5), FLORIDA ADMINISTRATIVE CODE CLASS II VIOLATION 57. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 58. A complaint investigation survey was conducted on May 16, 2011. Based on record review and interview, it was determined that the facility failed to discharge a resident who ° could no longer have their needs met and no longer met the criteria for continued residency in an ALF, for 1 out of 4 sampled residents ( Resident #2). The findings include the following. 59. Review of the file revealed resident #2 was admitted to facility on 03/19/10 from the hospital. Review of Resident Observation Notes dated 05/26/10 (one year prior) notes the Administrator had concerns regarding the facility's ability to provide care to the resident and the resident's suitability for an ALF. On 8/2/10 (3 months later), the facility documented the resident required a higher level of care and an RN 24 hours a day. 60. On 8/25/10, the resident was enrolled in hospice. An 19 interview with the Administrator at 11:50 AM on 05/16/11 confirmed that although the facility felt it could not provide the level of care the resident needed, he was allowed to remain at the facility. 61. Observations on 5/16/11 from approximately 9:30 AM to 4 PM, revealed resident #2 was sitting on the ‘couch, Slumped over, and did not. respond to prompts. Interview with a hospice representative on site on 5/16/11 at approximately 2:30 pM, revealed the resident's needs could not be met in the facility and required a higher level of care. Resident #2 was transferred to a nursing home on 5/16/11. 62. Based on the foregoing facts, Shalom Manor violated Rule 58A-5.0181(5), Florida Administrative Code, herein classified as a Class II violation, pursuant to Section 408.813(2) (6), Florida Statutes, and which warrants an assessed fine of $2,000.00 pursuant to Section 429.19(2)(b), Florida Statutes. 20 COUNT VIII SHALOM MANOR FAILED TO COMPLY WITH LOCAL FIRE DEPARTMENT TO ENSURE THE SAFETY AND WELL-BEING OF THE RESIDENTS. SECTION 429.41(1) (a), FLORIDA STATUTES RULE 58A-5.024(1) (m), FLORIDA ADMINISTRATIVE CODE CLASS II VIOLATION 63. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 64. An appraisal visit survey was conducted on June 6, 2011. Based on interview and record review, it was determined that the facility failed to comply with the local fire department to ensure the safety and well-being of the residents, ‘as required. The findings include the following. 65. During a review of the most recent fire inspection report dated 06/03/2011 it was revealed the facility was issued the following violations by the Lauderhill Pire Rescue Fire Prevention Bureau: a. Remove storage within 18 inches below sprinkler heads in food storage area. b. General disrepair - reduce amount of combustible storage in storage room. 66. Further review of the report revealed a re-inspection was scheduled for 06/06/2011. 21 67. During a telephone interview with the fire inspector of Lauderhill Fire Rescue Fire Prevention Bureau on 06/06/2011 at. approximately 3:00 PM, it was reported that he conducted a revisit to the facility on the morning of 06/06/2011. Further interview revealed as of the day of the re-inspection, 1 out of the 2 violations issued on 06/03/2011 remained outstanding specifically, failure to reduce the amount of combustible storage in the storage room, including boxes of files, -blankets and paper goods. The inspector reported a follow-up visit will be conducted in a "couple days" to ensure compliance. 68. Based on the foregoing facts, Shalom Manor violated Section 429.41(1) (a), Florida Statutes, and Rule 58A- 5.024(1) (m), Florida Administrative Code, herein classified herein classified as a Class II violation pursuant to Section 408.813(2)(b), which warrants an assessed fine of $2,000.00, pursuant to Section 429.19(2) (b), Florida Statutes. COUNT IX SHALOM MANOR FAILED TO ENSURE THAT AT LEAST ONE STAFF MEMBER TRAINED IN FIRST AID AND CPR IS PRESENT AT ALL TIMES. RULE 58A-5.019(4) (a)4, FLORIDA ADMINISTRATIVE CODE CLASS II VIOLATION 69. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 22 70. An appraisal visit survey was conducted on June 6, 2011. Based on record review and interview, it was determined that the facility failed to ensure at least one staff member, who is trained in First Aid and CPR, is present at all times when residents are in the facility. The findings include the following. 71. During record review, it was noted that several residents residing at the facility have diagnosis including mental health disorders, seizures, hypertension, chronic obstructive pulmonary disease, congestive heart failure, anemia and hyperlipidemia. The residents residing at the facility are unable to care for themselves independently and rely on staff to safeguard their well-being. 72. During a review of the staffing schedule, employee records, and interview with the Administrator, the Designated Relief Person, and the Office Manager on 06/06/2011 at approximately 12:00 PM, it was confirmed the facility does not have at least one staff member who is currently trained in First Aid, CPR, and AED present at all times when residents are in the facility on the following dates, times and shifts: 06/02/2011: 6AM to 7AM; 4 PM to 6 AM; 06/03/2011: 6AM to 7 AM; 06/04/2011: 6 AM to 3 PM; 06/05/2011: 6 AM to 3 PM; 06/06/2011: 6 AM to 7 AM. 73. During a further interview, the Administrator reported she was unaware there was not at least one staff member who is 23 trained in First Aid and CPR, present at all times when residents are in the facility. 74. Based on the foregoing facts, Shalom Manor violated Rule 58A-5.019(4) (a)4, Florida Administrative Code, herein classified as a Class II violation, pursuant to Section 408.813(2) (b), Florida Statutes, which warrants an assessed fine of $1,000.00, pursuant to Section 429.19(2) (b), Florida Statutes. 75. The violations subject of this case led to the filing of an Immediate Moratorium on Admissions on June 7, 2011: That case bears the number AHCA 2011006109. The Order was served upon Respondent the same day. REVOCATION SECTION 429.14(1) (e)1 & 2, FLORIDA STATUTES 75. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 76. Besides the fines sought in Counts I through IX of this complaint, the Agency seeks a revocation of license pursuant to Section 429.14(1)(e)1 & 2 , Florida Statutes, which provides that the Agency may revoke a license for one or more cited class I deficiencies or 3 or more cited class II deficiencies. 24 CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Shalom Manor on Counts I through IX. 2. Assess an administrative fine of $40,000.00 against Shalom Manor on Counts I through IX for the violations cited above. 3. Revoke the assisted living facility license [License No.: 5167] of Shalom Manor based on Counts I through IX for the violations cited above. 4, Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2010). 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 the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. 25 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 Alba M. 2 ft). Kod (\ 4 Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53°¢ Street Suite 300 Miami, Florida 33166 305-718-5911 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) 26 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Administrator, Shalom Manor, on this iw] qth Receipt Requested to Henry Emmins, 2771 N. W. 58 Terrace, Lauderhill, Florida 33313 ye Alba M. Rodri eZ, vad , 27 7009 O080 O000 0546 elle “U.S: Postal Service wn CERTIFIED: MAILa R (Domestic Mail-Only; No Insurani For.delivery information. visit our. web OFFICTIA Pastage Cortifd Fee Fleturn Recelpt Fae {Endorsement Required) Restricted Delivary Feo (Endorsement Required) Total Postage & Feas | SENDER: COMPLETE THIS SECTION 5 ooa8o0 on00 O58b 2012 ser pre ound ome Return ee

Docket for Case No: 11-003988

Orders for Case No: 11-003988