YO. 379 54am CYPRESS SQUARE ALS STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 99) pce _ ribs 3g . Se raed se dtc. STATE OF FLORIDA, AGENCY FOR HEALTH : CARE ADMINISTRATION, wit Petitioner, AHCA NO: 2002042271 vB. CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, O bd _ U7 U9 d/b/a CYPRESS COMMUNITY CARE CENTER Respondent. ADMINISTRATIVE COKPLAINT COMES NOW the Agency for Health Carve Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against CYPRESS MANOR HEALTH CARE ASSOCIATES, uLc, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter Respondent”) and alleges: NATURE _OF TRE ACTION 1. This is an action to impose an administrative fine in the amount of Two Thousand dollarg ($2,000) pursuant to Sections 400.102(2) (a) and (d), 400.121(1), amd 400,23(8) (c), Florida Statutes. 2. The Respondent waa cited for the uncorreated déficiency during the follow-up survey conducted on or about June 3-4, 2002, The original mandated correction date for the deficiency was 5/25/02, The fine for the deficiency is doubled because the facility was cited for a Class Il deficiency as a result of the April 2002 survey. “Yva coeoT e0/et/ tt 200%) Woy, 13, 2002 6:54AM CYPRESS SQUARE ALF dgurisdiction 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes, 4, venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28- 106.207 F.A,C. Parties 5. Afica ia the enforeing authority with regard to nursing home jicensure law pursuant to Chapter 400, Part II, Plorida Statutes and Rules S9A-4, Florida Administrative Code. 6. Regpondent is a nursing home located at 7173 Cypress Drive 8.W., Fort Myers, Florida 33907. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter S59A-4, Florida Administrative Code. couNT I RESPONDENT FAILED TO KEEP RESIDENTS FREE FROM UNNECESSARY DRUGS. FL. ADMIN CODE R.59A-4,1288 TNCORFORATING BY REFERENCE 42 CFR 483.25 (1) (1) UNCORRECTED Chass TIL DEFICIENCY 7. AHCA re-alleges and incorporates (1) threugh (6) as if fully set forth herein. a. on or about April 25, 2002 an annual survey wap conducted at the facility. 600 . : Yd CO:0T 20/ET/TT OY. 12.2002 8:54AM CYPRESS SQUARE ALF NG. 978 a 4 9, At that time, it wag determined, based on record review and staff interview, that 2 of 21 residents sampled were not free from unnecessary drugs. Resident #9 received psychoactive medication without adequate monitoring and Resident #17 received hypnotic medication for 10 days without a risk benefit statement or assesament cf the drug’s effectiveness. to. on or about dune 4, 2002 a revisit survey wags conducted at the facility, Based on resident recerd review and staff interview, one (resident #17) of 13 active residentea was not free from unnecessary drugs. This is evidenced by resident #17 being given Ativan without clinical documentation that the medication was needed. 11. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of {Two Thousand dollars ($2,000) is authorized under Sections 400,102 (2) (a) (a), 400.2121 (1), and 400.23(8) (a), Florida Statutes. WHEREFORE, ANCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose a fine of Two Thousand Dollars ($2,000) fox the violation cited in Count I, against the respondent under Sections 400.102(1) (a) and (4), 400,121(1), and 400.23(8)(c), Florida Statutes; Cc. Assess costs related to the investigation and prosecution of thig case pursuant to Section 400,221 Fl. Stat. (2001 D. All other general and equitable relief allowed by law. ro0D : “ ywa eotol go/eT/ TT The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes, Specific options for administrative action are ger out in the attached Explanation of Rights (one page) and Blection of Rights (one nage). All raquests for hearing shall be made to the attention of Eileen O'Hara Garcia, 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 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 SY THE AGENCY. Respectfully, submitted, Bileen O’Hara Garoia, AHCA - Senier Attorney 525 Mirror Lake Drive North, 330D St. Petersburg, Florida 33701 T HEREBY CERTIFY that a copy hereof has been furnished to CT Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 Return Receipt No. 7099 3400 0002 2450 7781, by U.S. Certified Mail and to Administrator, Cypress Community Care Center, 7173 Cypresea er Whee Drive §.W,, Fort Myers, FL 33907, U.S. Mail, on MN 2002, Eileen O’Hara Gartia, Esquire so0® - - , “FEXWa co:oT zo/ers Tt NOY. 13. 2002 €.55AM Copies furnished to: C T Corporation System Registered Agent for Cypress Community Care Center 120¢ South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Adminiatrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.8, Cartified Mail) Wendy Adams Agency for Health Care Administration 4727 Mahan Drive, Bldg #3 Ms #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O'Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330D St. Petersburg, Florida 33701 X¥d POS0T 900B cO/OT/TT

Docket for Case No: 02-004749