CN BASF STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2002000851 Return Receipt Requested: Vv. 7000 1670 0011 4845 8172 7000 1670 0011 4845 8967 CENTRAL PALACE RESIDENTIAL, INC. 7000 1670 0011 4845 9001 d/b/a CENTRAL PALACE RESIDENTIAL, INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA’), by and through the undersigned counsel, and files this Administrative Complaint against Central Palace Residential, Inc. d/b/a Central Palace Residential, Inc. (hereinafter “Central Palace Residential”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $2,393.00 pursuant to Sections 400.414, 400.419, Florida Statutes (2001), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Fla. Stat., Chapter 28-106, Florida Administrative Code. 3. Venue lies in Miami-Dade County, pursuant to Section 120.57 Fla. Stat, Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing adult living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2001), and Chapter S8A-5 Florida Administrative Code. 5. Central Palace Residential operates a 33-bed adult living facility located at 4491 S.W. 8 Street, Miami, Florida 33175. Central Palace Residential is licensed as an Adult Living Facility under license number 7107. Central Palace Residential 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 CENTRAL PALACE RESIDENTIAL FAILED TO HAVE A LNS LICENSE WHEN ACCEPTING A RESIDENT REQUIRING CARE OF A STAGE 2 PRESSURE SORE AND FAILED TO ENSURE THAT THE RESIDENT RECEIVED SERVICES PROVIDED PURSUANT TO A PLAN OF CARE ISSUED BY A LICENSED PHYSICIAN. RULE 58A-5.0181(1) (3) (1), (2), FLORIDA ADMINISTRATIVE CODE (ADMISSIONS CRITERIA) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Central Palace Residential was cited with two (2) Class II deficiencies pursuant to a complaint investigation conducted on November 30, 2001. 8. Based on a complaint investigation conducted on November 30, 2001, AHCA’s Surveyor found that Central Palace Residential failed to have a LNS license when accepting a resident requiring care of a stage 2 pressure sore and failed to ensure that the resident received services provided pursuant to a plan of care issued by a licensed physician. Findings include the following: 9. Pursuant to an interview with administrative staff and review of resident and facility records, the Surveyor found that resident #1, who was admitted with a decubitus ulcer/stage 2 pressure sore, and required services for treatment of the pressure sore, did not have a plan of care issued by a licensed physician, and therefore services were not provided to the resident pursuant to a plan of care. 10. Based on the foregoing, Central Palace Residential violated Rule 58A-5.0181(1) (4) (1), Florida Administrative Code, herein classified as a Class II violation, which carries an assessed fine of $1,000.00, pursuant to Section 400.419(1) (b), Fla. Stat. COUNT II CENTRAL PALACE RESIDENTIAL FAILED TO ENSURE THE APPROPRIATENESS OF A RESIDENT'S CONTINUED RESIDENCY IN THE FACILITY. ALTHOUGH A RESIDENT DETERIORATED, HE/SHE NEITHER RECEIVED APPROPRIATE/ADEQUATE SERVICES NOR WAS DISCHARGED TO AN APPROPRIATE CARE FACILITY. RULE 58475.0181(5), (4), and (1) (3) (3), AND RULE 58A-5.0182, FLORIDA ADMINISTRATIVE CODE (CONTINUED RESIDENCE AND DISCHARGE, RESIDENT CARE) CLASS II VIOLATION ll. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 12. Based on the complaint investigation conducted on November 30, 2001, the surveyor found that the facility failed to ensure the appropriateness of a resident's continued residency in the facility. Although a resident deteriorated, he/she neither received appropriate/adequate services nor was discharged to an appropriate care facility. Findings include the following: 13. Based on interview with administrative staff and review of resident and facility records, the surveyor found that resident #1, who was admitted with a decubitus ulcer/stage 2 pressure sore, developed edema of his/her lower extremities about four (4) days after being admitted and deteriorated progressively, to include his/her inability to ambulate and perform other activities of daily living, pain on his/her left arm which irradiated to his/her hand, headaches, insomnia and inappropriate behavior patterns; and the facility neither ensured that the resident received appropriate/adequate services (pursuant to Rule 58A-5.0182, F.A.C.), to meet her needs, nor discharged the resident to an appropriate health care facility in a timely manner, regardless of the family's wishes. 14. Based on the foregoing, Central Palace Residential violated Rule 58A-5.0181(5), (4), and (1) (5) (3), and Rule 58A-5.0182, Florida Administrative Code, herein Classified as a Class II violation, which carries an assessed fine of $1,000.00, pursuant to Section 400.419(1) (b), Fla. Stat. SURVEY FEE Pursuant to Section 400.419(9), Florida statutes, AHCA May assess a survey fee of $393.00 to cover the cost of complaint investigations and monitoring visits. CLAIM FOR RELIEF —— ee 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 Central Palace Residential on Counts I and IT. 2. Assess an administrative fine of $2,000.00 against Central Palace Residential for the two Class II violations cited in Counts I and II, pursuant to Section 400.419(1) (b), Fla. Stat. 3. Assess a Survey fee of $393.00 against Central Palace Residential, pursuant to Section 400.419(9), Fla. Stat. 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 (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 N. wW. 53rd Street, Miami, Florida, 33166; Attn: Kathryn F. Fenske. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING 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. Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 (Interoffice Mail) Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Kathryn F. Fenske Assistant General Counsel Agency for Health Care Administration Fla. Bar No.: 0142832 8355 N. W. 53 Street Miami, Florida 33166 (305) 499-2165 Adult Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE ED ERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Administrator, Central Palace Residential, 4491 5s. wW. 8 Street, Miami, Florida 33134; Central Palace Residential, Inc., 4491 S. W. 8 Street, Miami, Florida 33134; Efrain Rendon, 4845 S.W. 78 Street, Miami, Florida 33143 on this 44 day of 2002. Kathryn F. Fenske

Docket for Case No: 02-003259