Ce U STATE OF FLORIDA , AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 04-00-016-ALF vs. . THE ANDALL-FORBES ALF INC. d/b/a The Andall-Forbes ALF, Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY notified that after twenty-one (21) days from receipt of this Complaint, the Agency for Health Care Administration (hereinafter referred to as the “Agency”) intends to impose a civil penalty in the amount of $2,400.00 upon The Andall- Forbes ALF INC., d/b/a The Andall-Forbes ALF (hereinafter referred to as “Respondent”). As grounds for the imposition of this civil penalty, the Agency alleges as follows: (1) The Agency for Health Care Administration, State of Florida, has jurisdiction over the Respondent by virtue of the provisions to Chapter 400 Part III, Florida Statutes (1999), and Section 58A-5 Florida Administrative Code. (2) Respondent is licensed to operate as an Assisted Living Facility at 827 South Spring Garden Avenue, DeLand, Florida 32720, in compliance with Chapter 400, Part III, Florida Statutes (1999), and Chapter 58A-5, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400 Part III, Florida UU | U' Statutes (1999) and provisions of Chapter 58A-5, Florida Administrative Code, in that it was cited for eight (8) class III deficiencies during an ALF; ECC & LMH follow-up inspection conducted on April 13, 2000. These deficiencies set forth below, were previously cited during an ALF biennial licensure inspections conducted on February 25, 2000, and constitute, uncorrected deficiencies. (a) (A-608) The Respondent failed to maintain an accurate, up-to-date medication administration record for each resident. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.0182(6)(c), and Rule 58A-5.024(1)(c), Florida Administrative Code. Class III deficiency. Fine: $300.00. (b) (A609) The Respondent failed to ensure that prescription drugs were appropriately labeled as required. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.0182(6)(d)(1), Florida Administrative Code. Class III deficiency. Fine: $300.00. (c) (A902) The Respondent failed to maintain clean furnishings in good repair. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.022(1)(c), Florida Administrative Code. Class III deficiency. Fine: $300.00. (d) (L100) The Respondent failed to maintain an accurate and up-to-date log for admission & discharge of mental health residents. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.029(2)(a), Florida Administrative Code. Class III deficiency. Fine: $300.00. (e) (L101) The Respondent failed to assess each mental health resident for ability to live in an Assisted living facility. Cr U! This is a violation of Section 400.419(1)(c), and, Section 400.4075(3)(b), Florida Statutes (1999). Class III deficiency. Fine: $300.00. (f) (L102) The facility failed to provide documentation within 30 days of admission that residents were mental health residents. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.029(2)(c) 1, Florida Administrative Code. Class III deficiency. Fine: $300.00. (g) (L103) The Respondent failed to ensure that each mental health resident was covered by a community living support plan. This is a violation of Section 400.419(1)(c), and Section 400.400.4075(3)(a), Florida Statutes. Class III deficiency. Fine: $300.00. (h) (L107) The Respondent failed to ensure that each mental health resident has a cooperative agreement. This is a violation of Section 400.419(1)(c), and Section 400.4075(3)(a), Florida Statutes (1999). Class III deficiency. Fine: $300.00. (4) Notice was provided in writing to the Respondent of each of the above violations and the time frame correction. The agency is authorized to impose this fine pursuant to Section 400.419(1)(c), and Section 400.4075(3)(a), Florida Statutes (1999), and Chapter 58A-5, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations fore the operation of an ALF (Assisted Living Facility). (5) Respondent is notified that it has a right to request an administrative hearing pursuant to 120.57, 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 U , U! tecum issued, and to present written evidence or argument if it requests a hearing. Chapter 59-1, Part 2, 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 administrative hearing must conform to the requirements in Rule 28-5.201, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to dispute material issues of the fact in your request for a hearing may by treated by the Agency as election by you of an informal proceeding under Section 120.57 (2), Florida Statutes. All requests for hearing and payment of fines shall be made to the Agency for Health Care Administration, Office of Licensure and Certification, Attention: Michael O. Mathis, Senior Attorney. Mahan Drive, Tallahassee, Florida 32308 and Office of Finance and Accounting, Attention, Jim Michael, P.O. Box 12317, Tallahassee, Florida 32399- 3749 (Please reference the case number and facility name on the front of your check). (6) 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereby was sent U.S. Certified Mail, Return Receipt Requested, to Erma Forbes, Administrator, The Andall-Forbes ALF, 827 South Spring Garden Avenue, DeLand, Florida 32720, on this [2 te day of eke , 2000. Copies furnished to: Erma Forbes, Administrator The Andall-Forbes ALF 827 South Sring Garden Avenue DeLand, Florida 32720 (by U.S. Certified Mail) Agency for Health Care Administration Finance & Accounting P.O. Box 13749 Tallahassee, Florida 32317-3749 (by Interoffice Mail) wn Karen Swann ; Area 4 Office Supervisor Agency for Health Care Administration Health Quality Assurance 921 North Davis Street, Bldg. A, Suite 115 Jacksonville, FL 32209 Michael O. Mathis, Esquire Senior Attorney Agency for Health Care Administration 2727 Mahan Drive Building 3, Tallahassee, FL, 32308-3408 (by Interoffice Mail) Karen Swann Area 4 Supervisor Division of Health Quality Assurance 921 North Davis Street Building A, Suite 115 Jacksonville, Florida 32209 (by Interoffice Mail)

Docket for Case No: 00-003498