» pa/a4/ 2801 12:49 7275521448 AHCA PAGE 4&2 1 Division of A ink ‘ ee STATE OF FLORIDA | Gministrative Hearings & oe AGENCY FOR HEALTH CARE ADMINISTRAT! IN STATE OF FLORIDA | AGENCY FOR HEALTH [rine CARE ADMINISTRATION, | ate. (= T “Oy | Petitioner, vs. ANCA NO: 07-01-0149-NH BEVERLY HEALTHCARE KISSIMMEE (Beverly Enterprises Florida, Inc., d/b/a Beverly Healthcara Kissimmee) , Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against Beverly Enterprises Florida, Inc., d/b/a/ Beverly Healthcare Kissimmee (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1, This is an action to impose an administrative fine in the amount of one thousand ($1,000) dollars pursuant to Sections 400.23(8), 400.102(1) (a), (d), 400.121(1) Florida Statutes. -4a/e4/2801 12:43 7275521448 SHCA PAGE 43 Jurisdiction 2. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part IT, Florida Statutes. 3. Venue lies in Osceola County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 F.A.c. Parties 3. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 4. Respondent, Beverly Healthcare Kissimmee, is a nursing home located at 1120 West Donegan Avenue, Kissimmee, Florida. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Plorida Administrative Code. COUNT I ; RESPONDENT FAILED TO PROVIDE CARE IN ACCORDANCE WITH A RESIDENT’S WRITTEN PLAN OF CARE 59A-4,.1288, F.A.C. and 42 CFR 483.20 (k) (3) (ii) CLASS III DEFICIENCY 5. AHCA re-alleges and incorporates (1) through (4) as if fully set forth herein. 6. On or about Sune 14, 2001, the facility was cited for the deficiency set forth below. This deficiency was previously cited during a re-certification survey conducted on or about May | =r k t - 18/847 2801 12:49 7275521448 AHCA PAGE 44 10, 2001, and therefore, constitutes an uncorrected class TIT deficiency. 7. Based upon surveyor observations, resident record reviews and interviews, it was determined that the facility failed to follow the pressure sore care plan of one out of ten sampled residents so that the highest practicable well being of the resident could be preserved. : 8. The Respondent was given written notification of the cited deficiency containing a detailed description of the facts giving rise to the deficiency and the time frame for correction. 9. Based on the foregoing, Respandent violated 59A~-4.1288 F.A.C. adopting by reference 42 CFR 483.20(k) (3) (ii), which requixes that the services provided by the facility must be provided by qualified persons in accordance with each resident’s written plan of care. This is a repeat class III violation. The Agency ig authorized to impose a fine in the amount of $1,000.00 pursuant to Sections 400.23(8) (c), 400.102 (1) (a), (d), and 400.121(1) Florida Statutes. WHEREFORE, AHCA intends to impose a fine of one thousand dollars ($1,000) for the violation cited in Count I, against the respondent under Section 400.23(8)(c), Florida Statutes. - 18/04/2801 12:49 7275521440 AHCA PAGE 5 ’ The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2001). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Dennis L. Godfrey, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A BEARING 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. AHCA —- Senior Attorney 525 Mirror Lake Drive North Sebring Bldg., Suite 310L 8t. Petersburg, Florida 33701 (727) &52-1525 I HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt No. Z 170 444 503, to Corporation Service Company, 1201 Hays Street, Tallahassee, FL 32301-2525, ee ao pepare - 19/8472001 12:49 © 72785214aa AHCA Registered Agent for Beverly Enterprises Florida, the uth day of Poli, 2001. Copies furnished to: Long Term Care Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area 7 Office Agency for Health Care Administration Hurston Tower South 400 W. Robinson Street, $309 Orlando, Florida 33701 Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Administrator Beverly Healthcare Kissimmee 1120 West Donegan Avenue Kissimmee, Florida Inc., PAGE 6 on OTE CT eT gee REY eRe: BPI ee ee yer

Docket for Case No: 01-004530