STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, . OA U&Y vs. AHCA NO: 2002049287 WESTMINSTER COMMUNITY CARE SERVICES, INC., d/b/a WESTMINSTER CARE OF ORLANDO, 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 WESTMINSTER COMMUNITY CARE SERVICES, INC., d/b/a WESTMINSTER CARE OF ORLANDO, (hereinafter “Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes (2002), and alleges: NATURE OF THE ACTION 1. This is an action to assign a conditional license to WESTMINSTER COMMUNITY CARE SERVICES, INC., d/b/a WESTMINSTER CARE OF ORLANDO, pursuant to Section 400.23(7), Florida Statutes (2002). A copy of the original conditional license is attached hereto as Exhibit “A” and incorporated herein by reference. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 3. AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2002). 4, Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2002). PARTIES 5. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. WESTMINSTER COMMUNITY CARE SERVICES, INC., d/b/a ESTMINSTER CARE OF ORLANDO, is a Florida Non Profit company = with a principal address of 80 W. Lucerne Circle, Orlando, FL 32801. 7. WESTMINSTER CARE OF ORLANDO is a 420-bed skilled nursing facility located at 830 W. 29th Street, Orlando, Florida 32805. WESTMINSTER CARE OF ORLANDO is licensed by AHCA as a skilled nursing facility having been issued license number SNF1156096 certificate number 9553, with an effective date of October 29, 2002 and an expiration date of September 28, 2003. 8. WESTMINSTER CARE OF ORLANDO is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part II, Florida Statutes and Chapter S9A-4, Florida Administrative Code. COUNT _I EFFECTIVE OCTOBER 29, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO WESTMINSTER CARE OF ORLANDO, BASED UPON THE DETERMINATION THAT WESTMINSTER CARE OF ORLANDO WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF TWO (2) UNCORRECTED CLASS III DEFICIENCIES, ORIGINALLY CITED ON SEPTEMBER 12, 2002, DURING THE SURVEY OF OCTOBER 29, 2002, AS AUTHORIZED UNDER § 400.23(7) (b), Fla. Stat. 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. On or about October 29, 2002, AHCA conducted a follow- up to the annual survey of September 9-12, 2002, at WESTMINSTER CARE OF ORLANDO. Two (2) uncorrected class III deficiencies were cited against Respondent based on the findings set forth below. FIRST UNCORRECTED CLASS III DEFICIENCY 11. Based on observation, it was determined that the Respondent failed to ensure that the resident environment remained free of accident hazards in 2 of 4 wings on the first floor of the facility. 12. Specifically: a) During the tour of the facility on 10/28/02, at 12:00 p.m., on the B Wing (the secured unit), the surveyor observed a disposable razor in a plastic bag laying on a shelf in an unoccupied resident room. The door to the room was open and was accessible to wandering residents. b) During the tour of the facility on 10/28/02 at 12:10 p.m., on the G Wing, the surveyor observed a small plastic cup of a brownish-yellow liquid sitting on a bedside table in a resident room. The liquid was not labeled and was in full view of other residents. 13. This is in violation of Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 CFR 483.25(h) (1), and Section 400.141(8), Florida Statutes, that requires the facility ensure that the resident environment remains as free of accident hazards as is possible, and maintain the facility’s premises and conduct its operations in a safe manner. SECOND UNCORRECTED CLASS III DEFICIENCY 14. Based on observation, it was determined that the facility failed to ensure that drugs were stored in locked compartments on the H Wing of the facility. 15. Specifically: a) On 10/29/02 at 9:15AM, the surveyor entered the H Wing and observed a medication cart in the hallway outside of room 1007. The cart was unattended by the licensed nurse. The nurse was then observed walking down the hall toward the cart, entered a resident room, closed the resident room door and left the cart unattended again. The surveyor observed a unattended and in full view of residents, staff and visitors. 16. This is in violation of Rule 59A-4.112(6), and Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 CFR 483.60(e), Florida Statutes, that requires the facility to store drugs and non-prescription medication that require refrigeration be stored in a refrigerator in a separate, covered, waterproof labeled receptacle, and to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 17. AHCA assigned a conditional licensure status to WESTMINSTER CARE OF ORLANDO based upon the determination that the facility was not in substantial compliance with applicable laws and rules due to the presence of two (2) uncorrected Class III deficiencies at the most recent survey on or about October 29, 2002. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make actual and legal findings in favor of AHCA on Count I; 2) Uphold the issuance of the conditional license with an effective date of 10/29/02, a copy of which is attached hereto as Exhibit “A”; and 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002). DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, WESTMINSTER CARE OF ORLANDO shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE WESTMINSTER CARE OF ORLANDO hereby 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 set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Michael P. Sasso, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, #330K, St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY ACHA. jy Th Respectfully submitted on this /7 day of January, 2003. Michael P. Sasso, Esquire Fla. Bar. No. 0167363 525 Mirror Lake Drive North, 330K St. Petersburg, Florida 33701 (727) 552-1435 (office) (727) 552-1440 (fax) CERTIFICATE OF SERVICE TI HEREBY CERTIFY that the original Administrative Complaint and Exhibit “A” has been furnished to Michael J. Bittman, Registered Agent for Westminster Care of Orlando, 301 East Pine Street, Suite 1400, Orlando, Florida 32801, via postage paid U.S. Mail, Return Receipt No. 7002 2030 0002 7117-6444 and to Diane King, Administrator, Westminster Care of Orlando, 830 West 29 street, Orlando, Florida 32805, Return Receipt No.7002 2030 0002 7117 6451, on January /4¢™ 2003. chal [hove Michael P. Sasso, Esquire COPIES TO: Michael J. Bittman Registered Agent for Westminster Care of Orlando 301 East Pine St, Suite 1400 Orlando, FL 32801 (U.S. Certified Mail) Diane King, Administrator Westminster Care of Orlando 830 West 29°? Street Orlando, FL 32805 (U.S. Certified Mail) Michael P. Sasso, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330K St. Petersburg, Florida 33701 Exhibit “A” CONDITIONAL LIC License # SNF1156096; Cer ENSE tificate #9553 Effective Date: 10/29/2002 Expiration Date: 9/28/2003

Docket for Case No: 03-001166