STATE OF FLORIDA Loe, AGENCY FOR HEALTH CARE ADMINISTRATION) y i Jay STATE OF FLORIDA 7" AGENCY FOR HEALTH CARE Aon Sle ADMINISTRATION, bed S7 ae Petitioner, CASE NO: 2003003971 vs. SHADY OAKS LIVING CENTER, INC., 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 SHADY OAKS LIVING CENTER, INC., (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine and survey fee on Respondent in the amount of one thousand seven hundred seventy-five dollars ($1,775) pursuant to Section 400.419(1) (c) Florida Statutes. 2. The Respondent is cited for the deficiency set forth below as a result of a Complaint Survey completed on May 22, 2003. The violations cited are three (3) repeat Class III deficiencies, originally cited at a Complaint Investigation on or about May 28, 2001. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 4. Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. PARTIES S. AHCA, Agency for Health Care Administration, State of Florida is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 2208 East 138 Avenue, Tampa, FL 33612. Respondent is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I RESPONDENT FAILED TO ENSURE THAT THE FACILITY’S PHYSICAL STRUCTURE, INCLUDING THE INTERIOR AND EXTERIOR WALLS, FLOORS, ROOF AND CEILINGS SHALL BE STRUCTURALLY SOUND AND IN GOOD REPAIR. VIOLATING RULE 58A-5.023(1) (b), F.A.C., REPEAT CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. A complaint survey was conducted on May 28, 2001. 9. On that date, based on a tour of the facility, the facility’s physical structure was not in good repair: a leak was observed in the dining area, the water dripping onto the floor from a large, discolored area in the ceiling. 10. These observations were cited as a Class III deficiency with a mandated correction date of June 18, 2001. They were corrected at the follow-up visit on August 10, 2001. 11. A complaint survey was conducted on or about May 22, 2003. 12. On that date, based on observation, the facility’s interior structure is not structurally sound nor in good repair. The findings include: During a tour of the facility conducted on 5/22/03 at 1:20pm, the south wall in room #24 was observed to numerous gaps at the junction of the wall and the floor. In some areas at the junction of the south wall and the floor, gaps in excess of one-half an inch were noted. These gaps consisted of areas where the plaster wall had broken off/away from the floor. 13. This is a violation of Rule 58A-5.023(1) (b), Florida Administrative Code which requires the facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair. 14. The above referenced violation constitutes the grounds for the imposed repeat Class III deficiency and for which a fine of five hundred dollars ($500) is authorized pursuant to Section 400.419(1)(c) Florida Statutes (2002). COUNT II RESPONDENT FAILED TO ENSURE THAT THE FACILITY’S WINDOWS, DOORS, PLUMBING AND APPLIANCES SHALL BE FUNCTIONAL AND IN GOOD WORKING ORDER. VIOLATING RULE 58A-5.023(1) (b), F.A.C., REPEAT CLASS III DEFICIENCY 15. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 16. A complaint survey was conducted on May 28, 2001. 17. On that date, based on a tour of the facility, and of observations of the women’s bathroom, two of the toilets in the women’s bathroom are not in good working order: one toilet does not have a tank lid, another toilet is not functioning and is taped off with a “do not use” sign. 18. These observations were cited as a Class III deficiency and were corrected at the follow-up visit on August 10, 2001. 19. A complaint survey was conducted on or about May 22, 2003. 20. On that date, based on observation and on interview with one resident, the facility has failed to maintain all doors in good working order. The findings include: During a tour of the facility conducted 5/22/03 at 1:10pm, the door to resident bedroom #12 was observed to not have a doorknob; anyone in the hallway could see directly into the room. During an interview with one resident of room #12, conducted 5/22/03 at 1:30pm, the resident stated that the doorknob had been removed "over a month ago" due to one roommate locking out the other roommate. 21. This is a violation of Rule 58A-5.023(1) (b), Florida Administrative Code which requires that windows, doors, plumbing, and appliances shall be functional and in good working order. 22. The above referenced violation constitutes the grounds for the imposed repeat Class III deficiency and for which a fine of five hundred dollars ($500) is authorized pursuant to Section 400.419(1)(c) Florida Statutes (2002). COUNT III RESPONDENT FAILED TO ENSURE THAT THE FACILITY’S FURNITURE AND FURNISHINGS WERE CLEAN, FUNCTIONAL, FREE-OF-ODORS, AND IN GOOD REPAIR. VIOLATING RULE 58A-5.023(1) (b), F.A.C., REPEAT CLASS III DEFICIENCY 23. AHCA re-alleges and incorporates through (6) as if fully set forth herein. 24. A complaint survey was conducted 25. On that date, based on a tour of facility contains furnishings that are not of the beds in room 23 has a mattress that cracked. paragraphs (1) on May 28, 2001. the facility, the in good repair: one is torn, slit and 26. These observations were cited as a Class III deficiency and were corrected at the follow-up visit on August 10, 2001. 27. A complaint survey was conducted on or about May 22, 2003. 28. On that date, based on a tour of the facility conducted on 5/22/03 at 11:15 a.m., the south bed in resident bedroom #24 was noted to have a mattress which was torn and cracked. 29. This is a violation of Rule 58A-5.023(1) (b), Florida Administrative Code which requires that all furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. 30. The above referenced violation constitutes the grounds for the imposed repeat Class III deficiency and for which a fine of five hundred dollars ($500) is authorized pursuant to Section 400.419(1)(c) Florida Statutes (2002). ADDITIONAL FEE UNDER SECTION 400.419(9), FLORIDA STATUTES 31. The Respondent has been cited for three (3) repeat Class III deficiencies as a result of a complaint and therefore is subject to a survey fee of $275.00 pursuant to Section 400.419(9), Florida Statutes. 32. Notice was provided in writing to the Respondent of the violation and the time frame for correction WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order relief with fines and survey fee against the Respondent pursuant to Section 400.419(1)(c) Florida Statutes in the amount of one thousand seven hundred seventy-five dollars ($1,775.00). 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 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: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Wayne D/ Knight, E AHCA - Senior Attorney Fla. Bar No. 0136440 525 Mirror Lake Drive North, 330L St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Joseph W. Joseph, Administrator/Registered Agent for Shady Oaks Living Center, Inc., 2208 East 138% Avenue, Tampa, FL 33613, Return Receipt No. 7003 1010 0003 4303 8494 by U.S. Certified Mail on December S , 2003. J, Copies furnished to: Joseph W. Joseph, Administrator Registered Agent for Shady Oaks Living Center, Inc. 2208 East 138° Avenue Tampa, FL 33613 (Certified U.S. Mail) Wayne D. Knight, Esq. Senior Attorney 525 Mirror Lake Drive Suite 330L St. Petersburg, Fl 33701

Docket for Case No: 04-000382