een TT TE SE SR STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMI NISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2005004465 MAPLEWAY COMMUNITY, INC., 0 s . 2 \ 7 Xx Respondent. / n= ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against MAPLEWAY COMMUNITY, INC. (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57, Fla. Stat. (2004), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of EIGHT THOUSAND DOLLARS ($8,000.00), pursuant to § 400.419(2), Fla. Stat. (2004), and a complaint survey fee in the amount of ONE HUNDRED SIXTY-ONE AND 50/100 DOLLARS ($161.50), pursuant to §§ 400.419(10) and 400.428(3)(c), Fla. Stat. (2004), based upon the existence of one (1) Class I and three (3) Class I deficiencies at the Respondent’s facility. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2004). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable regulations, statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part III, Fla. Stat., and Chapter 58A-5 Fla. Admin. Code. 4. Respondent operates a 20-bed assisted living facility located at 475 Maple Way, Safety Harbor, Florida 34695, and is licensed as an assisted living facility (License No. 8504). 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. Pursuant to Fla. Admin. Code R. 58A-5.019(4)(b), notwithstanding the minimum staffing ratio, all facilities, including those composed of apartments, shall have enough qualified staff to provide resident supervision, and provide or arrange for resident services in accordance with resident scheduled and unscheduled service need, resident contracts and resident care standards. 8. On or about May 5, 2005, the Agency conducted a biennial licensure survey of the Respondent’s assisted living facility (hereinafter “Facility”), in conjunction with a limited mental health license survey and complaint investigation (CCR# 2005002944). 9. Based upon review of the Facility’s staffing schedule and employee training records, and based on interview of the Facility staff, the Agency determined that the Respondent failed to provide or arrange for resident services in accordance with scheduled and unscheduled service needs of the Facility’s resident population. 10. Review of the residents’ health assessments and behavioral assessments revealed that Residents #2, #3 and #8 are deaf and communicate via sign language. 11. Iman interview conducted on or about May 5, 2005, at approximately 2:30 p.m., the Facility administrator (hereinafter “ Administrator”) indicated that the Facility owner, three (3) resident assistants and the assistant administrator (hereinafter “Assistant Administrator”) were trained in sign language. 12. In an interview conducted on or about May 5, 2005, at approximately 6:00 p.m., the Assistant Administrator indicated that of the nine (9) residents that resided at the Facility during the May 5, 2005, survey, four (4) were deaf and mute and one (1) resident was only deaf. 13. During that same interview, the Assistant Administrator further indicated that the above-described residents mainly communicated via sign language to some degree or another. 14. Other residents of the Facility do not use sign language as a means of communication. 15. On or about May 5, 2005, review of the direct care staff schedule for the week of April 24th through April 30th, 2005, indicated that the resident assistant that was scheduled to be on duty during the 11:00 p.m. — 7:00 a.m. shift of that time period was not trained in sign language. 16. | Onor about May 5, 2005, review of the direct care staff schedule for the week of April 24th through April 30th, 2005, indicated that both resident assistants that were scheduled to be on duty during the 7:00 a.m. —3:00 p.m. shift on Saturday and Sunday of that time period were not trained in sign language. 7. In an interview conducted on or about May 5, 2005, at approximately 7:30 p.m., the Administrator confirmed that on the 11:00 p.m. to 7:00 a.m. shift only one (1) staff member is typically scheduled. He also verified that there was usually only two (2) to three (3) staff that work on the 3:00 p.m. to 11:00 p.m. shift. The Administrator further indicated that the owners live next door to the Facility and the residents sleep at night. 18. Review of Residents #2, #3 and #8's Behavior Assessments revealed that those residents all have aggression that can be acted out by hitting, punching or shoving. 19. Residents #2 and #8 have required involuntary hospitalization on more than one occasion for their poor impulse control and behavior management issues. 20. During dinner on the May 5, 2005, survey, only two (2) staff members were present with the residents during dinner. Those two (2) staff members were the only staff scheduled to be present. 21. During dinner on the May 5, 2005, survey, one of the staff members working was also deaf. Although that staff member is able to communicate exceptionally well with the deaf residents, the staff member must have residents and/or staff in sight to be aware of needs/concerns that may arise, thereby placing residents and/or staff at risk if they are unable, for whatever reason, to catch the attention of the deaf staff member to communicate or express immediate and/or emergent needs/concems. 22. During an exit interview conducted on or about May 5, 2005, at approximately 7:30 p.m., an Agency surveyor explained to the Administrator the concerns/risks created by not having trained staff to communicate with residents on all shifts. 23, During an exit interview conducted on or about May 5, 2005, at approximately 7:30 p.m., an Agency surveyor explained to the Administrator that the Facility placed residents and staff at risk by not having at least two (2) staff members on duty at all times to meet the scheduled and unscheduled needs of this specialized resident population. 24. Based upon the above, the Agency determined that the Respondent failed to have enough qualified staff to provide resident supervision, and provide or arrange for resident services in accordance with resident scheduled and unscheduled service need, resident contracts and resident care standards, in violation of Fla. Admin. Code R. 58A-5.019(4)(b). 25. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of residents, and directly threatened the physical or emotional health, safety, or security of the facility residents. 26. The Agency cited the Respondent for a Class I deficiency in accordance with § 400.419(2)(b), Fla. Stat. (2004). 27. The Agency provided Respondent with a mandatory correction date of May 5, 2005. 28. Respondent’s failure to have enough qualified staff to provide resident supervision, and provide or arrange for resident services in accordance with resident scheduled and unscheduled service need, resident contracts and resident care standards, in violation of Fla. Admin. Code R. 58A-5.019(4)(b), as set forth in this count, constitutes grounds for the imposition of an administrative fine in the amount of ONE THOUSAND DOLLARS ($1000.00), pursuant to § 400.419(2)(b), Fla. Stat. (2004). WHEREFORE, the Agency intends to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). COUNT II 29. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 30. Pursuant to Fla. Admin. Code R. 58A-5.019(4)(b), notwithstanding the minimum staffing ratio, all facilities, including those composed of apartments, shall have enough qualified staff to provide resident supervision, and provide or arrange for resident services in accordance with resident scheduled and unscheduled service need, resident contracts and resident care standards. 31. On or about May 12, 2005, the Agency conducted a complaint investigation (CCR# 2005004016) of the Respondent’s assisted living facility (hereinafter “Facility”). 32. Based upon review of the Facility’s staffing schedule, employee training records, and resident records, and based on interview of the Facility staff, the Agency determined that the Respondent failed to provide or arrange for resident services in accordance with scheduled and unscheduled service needs of the Facility’s resident population. 33. In an interview conducted on or about May 12, 2005, at approximately 11:15 a.m., the Facility’s owner (hereinafter “Owner”) indicated that on May 8, 2005, the Facility census was nine (9) residents. 34. During a May 5, 2005, survey, record review revealed that five (5) of the Facility residents are deaf and their main way of communicating is via sign language. 35. The resident population consisted of dually diagnosed residents with varying degrees of mental retardation and psychiatric issues. Many of those residents had exhibited aggression that included the need for police involvement and involuntary hospitalization. 36. Review of the Admission/Discharge Log revealed that the resident population was unchanged from the May 5, 2005, visit to the Facility. 37. During an exit interview conducted following the May 5, 2005, survey, an Agency surveyor explained to the Administrator the concerns/risks created by not having trained staff to communicate with residents on all shifts. During that same exit interview, the Agency surveyor explained to the Administrator that the F acility placed residents and staff at risk by not having at least two (2) staff members on duty at all times to meet the scheduled and unscheduled needs of this specialized resident population. 38. Review of the facility staffing schedule for May 8, 2005, revealed that the Facility only had one (1) staff member that worked from 2:00 p.m. to 10:00 p.m. and one (1) employee that worked from 4:00 p.m. to 11:00 p.m. 39. Record review of employee files revealed only three (3) resident assistants and the assistant administrator had been trained in sign language. In addition, the owner of the Facility is also able to communicate via sign. 40. The staff member that worked from 2:00 p.m. to 10:00 p.m. on May 8, 2005, is deaf and communicates very effectively via sign. Al. The employee that worked alone from 10:00 p.m. to 11:00 p.m. on May 8, 2005, had not received any training in sign. 42. In an interview conducted on or about May 12, 2005, at approximately 11:30 am., the Facility owner (hereinafter “Owner”) indicated that he had to contact the police at approximately 10:30 p.m. on May 8, 2005, because of employee to resident abuse. The reported abuse involved a Facility employee raping a resident while the employee was the only staff member on duty. Such presence of inadequate staff created an unsafe environment in which the sole employee was able to harm a vulnerable resident. 43. Based upon the above, the Agency determined that the Respondent failed to have enough qualified staff to provide resident supervision, and provide or arrange for resident services in accordance with resident scheduled and unscheduled service need, resident contracts and resident care standards, in violation of Fla. Admin. Code R. 58A-5.019(4)(b). 44. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of residents, and directly threatened the physical or emotional health, safety, or security of the facility residents. 45. The Agency cited the Respondent for a Class II deficiency in accordance with § 400.419(2)(b), Fla. Stat. (2004). 46. The Agency provided Respondent with a mandatory correction date of May 5, 2005. 47. Respondent’s failure to have enough qualified staff to provide resident supervision, and provide or arrange for resident services in accordance with resident scheduled and unscheduled service need, resident contracts and resident care standards, in violation of Fla. Admin. Code R. 58A-5.019(4)(b), as set forth in this count, constitutes grounds for the imposition of an administrative fine in the amount of ONE THOUSAND DOLLARS ($1000.00), pursuant to § 400.419(2)(b), Fla. Stat. (2004). WHEREFORE, the Agency intends to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). COUNT IL 48. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 49. Pursuant to Fla. Admin. Code R. 58A-5.0185(5)(c), for medications that serve as chemical restraints, an assisted living facility must maintain a record of the prescribing physician’s annual evaluation of the use of such medications. 50. Pursuant to § 400.402 (7), Fla. Stat. (2004), a chemical restraint is defined as a pharmacologic drug that physically limits, restricts, or deprives an individual of movement or mobility, and is used for discipline or convenience and not required for the treatment of medical symptoms. 51. On or about May 5, 2005, the Agency conducted a biennial licensure survey of the Respondent’s assisted living facility (hereinafter “Facility”), in conjunction with a limited mental health license survey and complaint investigation (CCR# 2005002944). 52. Based on reports from the Agency for Persons with Disabilities (hereinafter “APD”), resident record reviews and interviews, the Agency determined that the Respondent failed to maintain a record of the prescribing physician's annual assessment for medications that can be classified as chemical restraints for four (4) of the residents sampled (Residents #2, #3, #4, and #5). 53. A report from a clinical pharmacist working in conjunction with APD, which was dated March 28, 2005, and addressed to the Supervisor for the Medical Case Management Team for the APD, revealed the following summary of the medication problems found during a review of Respondent facility: The reviewer could not ascertain a rationality of the pharmacotherapy employed, patients received multiple medications, some of which were redundant antipsychotic and anticonvulsant medications, patients received on average at least two antipsychotic and anticonvulsant agents. It could appear that medications are being used for the convenience of staff. This is based upon the following: 1. Lack of a comprehensive behavioral treatment plan containing specific and measurable goals for pharmacotherapy. 2. Over reliance on psychotropic and anticonvulsant medications to control behavior. 3. Psychotropic and anticonvulsant doses that begin to bridge the upper limits of these medications. 4. Reliance on PRN medications; a line of responsibility to a licensed healthcare professional is not always demonstrated; medication orders allow unlicensed staff to make judgments and decisions regarding when to use medication, how much medication to use, and frequency of medication use. 5. There are a number of drug-drug interactions; i.e. increased risk of absence seizures; increased risk of central and peripheral anticholinergic syndrome; increased risk of serotonin syndrome; increased risk to toxic serum concentrations. 6. Lack of monitoring for the presence of the metabolic syndrome. 7. Lack of discernable goals and outcomes for behavior; behaviors are learned phenomena not necessarily pathological phenomena. 54. In an interview conducted on or about May 5, 2005, at approximately 1:15 p.m., the Supervisor for the Medical Case Management Team for the APD indicated that she had met with the owners and administrators of the Facility to review the findings of the March 28, 2005, report. 55. In that same interview, the Supervisor for the Medical Case Management Team for the APD indicated that on April 14, 2005, she sent a letter to the attending physician for residents at the Facility that addressed the concerns expressed in the March 28, 2005, report. 56. | Onor about May 2, 2005, a coordinated joint meeting took place and was attended by the owners, administrator, and assistant administrator of Facility, an ARNP for the attending physician, and several others. This meeting was called to discuss the interventions and plans of action in response to the concerns related to medications used as chemical restraints. 57. In an interview conducted on or about May 5, 2005, at approximately 4:10 p.m., the Facility administrator revealed that the Facility had hired a consultant pharmacist on May 2, 10 2005, but that copies of resulting reports and/or recommendations were not yet available. 58. Resident #2’s May 2005 Medication Record revealed the resident was currently receiving the following medications, which could be classified as chemical restraints: Trazadone 100 mg. tablet every evening Geodon 80 mg. capsule twice daily Depakote 250 mg. tablet every morning and 500 mg. every night Prolixin 5 mg. tablet twice daily Cogentin 0.5 mg. tablet teice daily Prozac 20 mg. by mouth daily 59. Resident #3’s May 2005 Medication Record revealed the resident was currently receiving the following medications, which could be classified as chemical restraints: Loxapine Succinate 25 mg. every morning Lorazepam 1 mg. tablet twice daily and 1 tablet at 9:00 p.m. Zyprexa 5 mg. tablet every morning Depakote 500 mg. tablet - 2 tablets by mouth every morning Lexapro 10 mg. tablet by mouth every morning Seroquel 50 mg. every morning and 100 mg. at bedtime Artane 2 mg. tablet three times daily - Diagnosis EPS 60. Resident #4’s May 2005 Medication Record revealed the resident was currently receiving the following medications, which could be classified as chemical restraints: Lithium Carbonate 300 mg. capsule daily Depakote 500 mg. tablet at 4:00 p.m. Paxil 30 mg. tablet every morning Cogentin 1 mg. tablet every morning Zyprexa 10 mg. by mouth twice daily Risperdal 1 mg. by mouth twice daily 61. Resident #5’s May 2005 Medication Record revealed the resident was currently receiving the following medications, which could be classified as chemical restraints: Risperdal 0.5 mg. - half tablet at 4:00 p.m. Nexium 40 mg. capsule daily Sensipar 30 mg. tablet daily Tarka 4/240 mg. daily Zyprexa 20 mg, - half tablet every morning and at bedtime Diazepam 5 mg. twice daily on Monday - Wednesday - Fridays 11 Clonidine HCL 0.2 mg. tablet twice daily 62. Review of Resident #3’s Behavioral Assessment dated November 11, 2002. revealed that that resident had, in the past, received Cogentin 1 mg. BID to help reduce and/or abate the side effects caused by anti-psychotic medications. 63. During the dinner meal on May 5, 2005, an Agency surveyor observed Resident #3 exhibiting facial and oral movements of the forehead and cheeks and grimacing. Such abnormal involuntary movements may be caused by tardive dyskinesia, a muscular side effect associated with anti-psychotic medications. 64. During the dinner meal on May 5, 2005, an Agency surveyor observed Resident # 4 communicating with peers and staff in an animated manner. The resident exhibited exaggerated hand and wrist movements, as well as some lip and jaw movements, that appeared abnormal involuntary type movements and may have been side effects associated with that resident’s use of chemical restraint-type medications. 65. Records for Residents #3 and #4 did not contain a baseline for all involuntary physical movements of those residents against which to compare the involuntary physical movements associated with the use of chemical restraints. Such a baseline evaluation would have been included as part of an annual evaluation by the prescribing physician for the chemical restraints prescribed to those residents. 66. Record review revealed no annual evaluation by the prescribing physician for the chemical restraints prescribed to Residents #2, #3, #4, and #5. Such evaluation would address dosages, duplication in medications, and side effects noted by ADP and the observed by the Agency surveyor(s). Failure to conduct such evaluation, and to maintain a written record thereof, constitutes a direct threat to the health of residents receiving medications that serve as physical restraints, as such evaluations are necessary to determine whether such medications are adequately and safely addressing the needs of residents. 67. Based upon the above, the Agency determined that the Agency determined that the Respondent failed to maintain a record of the prescribing physician's annual assessment for medications that can be classified as chemical restraints for four (4) of the residents sampled, in violation of Fla. Admin. Code R. 58A-5.0185(5)(c). 68, The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of residents, and directly threatened the physical or emotional health, safety, or security of the facility residents. 69. The Agency cited the Respondent for a Class II deficiency in accordance with § 400.419(2)(b), Fla. Stat. (2004). 70. The Agency provided Respondent with a mandatory correction date of May 17, 2005. 71. Respondent's failure to maintain a record of the prescribing physician's annual assessment for medications that can be classified as chemical restraints, in violation of Fla. Admin. Code R. 58A-5.0185(5)(c), as set forth in this count, constitutes grounds for the imposition of an administrative fine in the amount of ONE THOUSAND DOLLARS ($1000.00), pursuant to § 400.419(2)(b), Fla. Stat. (2004). WHEREFORE, the Agency intends to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). COUNT IV 72. The Agency re-alleges and incorporates paragraphs one (1) th rough five (5) as if 13 fully set forth herein. 73. Pursuant to § 400.428(1) Fla. Stat. (2004), an assisted living facility is required to comply with the Resident Bill of Rights. 74, Pursuant to § 400.428(1)(a) Fla. Stat. (2004), every resident of an assisted living facility has the right to live in a safe and decent living environment, free from abuse and neglect. 75. Pursuant to § 415.102(1), Fla. Stat. (2004), “abuse” is any willful act or threatened act by a caregiver that causes or is likely to cause significant impairment to a vulnerable adult's physical, mental, or emotional health, and includes both acts and omissions. 76. Pursuant to § 415.102(15), Fla. Stat. (2004), “neglect” is the failure or omission on the part of the caregiver to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult, including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, that a prudent person would consider essential for the well-being of a vulnerable adult. The term “neglect” also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult from abuse, neglect, or exploitation by others. “Neglect” is repeated conduct or a single incident of carelessness that produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. 77. On or about May 12, 2005, the Agency conducted a complaint investigation (CCR# 2005004016) of the Respondent’s assisted living facility (hereinafter “Facility”. 78. Based on record review and interviews, the Agency determined that the Respondent failed to provide for a safe environment, free of abuse and/or neglect for one (1) of three (3) sampled residents (Resident #1). 79. Record review of Resident #1's Health Assessment, dated April 8, 2004, revealed that Resident #1 has been diagnosed with mild mental retardation and schizophrenia. 80. Record review of Resident #1's Developmental Support Plan, dated June 6, 2004, described the Resident as being a "friendly" woman, who is sometimes shy and quiet until she gets to know you. 81. In an interview conducted on or about May 12, 2005, at approximately 12:45 p-m., Resident #1 revealed that she was forced to have sex with an employee. 82. In that interview, Resident #1 stated that on May 8, 2005, at approximately 10:30 p.m., a Facility employee came into her bedroom, closed the door, and reached out and touched Resident #!’s hair. Resident #1 indicated that she told the employee she didn’t like being touched in such a manner and asked the employee to stop. 83. Inthe interview, Resident #1 indicated that the employee told her he wanted to have sex with her. Resident #1 indicated that she told the employee no, but that the employee forced her to have sex with him anyway. 84. Resident #1 described in explicit detail how the employee climbed on top of her, penetrated her with his penis, and licked her breast and private area. 85. Resident #1 indicated that she again told the employee to stop, but that he did not do so. 86. Resident #1 indicated that the employee was hurting her and that she felt the employee was disgusting. 87. Resident #1 indicated that the employee didn't wear a condom and, as a result, she was concerned about contracting AIDS. 88. In an interview conducted on or about May 12, 2005, at approximately 11:15 a.m., the Facility owner (hereinafter “Owner”) revealed the following: a. On the night of May 8, 2005, at approximately 10:30 p.m., after noting the absence of lights at the therein, the Owner walked over to the Facility. b. After entering the Facility, Resident #1's bedroom light came on and the Owner entered to find the employee in the room with that resident. c. Resident #1 described to the Owner the incident that had just occurred. d. The Owner asked the employee if he had sex with the resident, and the employee responded in the affirmative. e. The Owner contacted the police to report the event. 89. Based upon the above, the Agency determined that the Agency determined that the Respondent failed to provide a safe and decent living environment, free from abuse and/or neglect, in violation of § 400.428(1)(a) Fla. Stat. (2004). 90. | The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and presented an imminent danger to the residents or guests of the Facility or a substantial probability that death or serious physical or emotional harm would result therefrom. 91. | The Agency cited the Respondent for a Class I deficiency in accordance with § 400.419(2)(a), Fla. Stat. (2004). 92. The Agency provided Respondent with a mandatory correction date of May 17, 2005. 93. Respondent’s failure provide a safe and decent living environment, free from abuse and neglect, in violation of § 400.428(1)(a) Fla. Stat. (2004), as set forth in this count, constitutes grounds for the imposition of an administrative fine in the amount of FIVE THOUSAND DOLLARS ($5000.00), pursuant to § 400.419(2)(a), Fla. Stat. (2004). WHEREFORE, the Agency intends to impose an administrative fine in the amount of FIVE THOUSAND DOLLARS $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(a), Fla. Stat. (2004). COUNT V 94. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and seventy-three (73) through ninety-three (93) as if fully set forth herein. 95. Pursuant to § 400.419(10), Fla. Stat. (2004), the Agency may assess a survey fee, in addition to any administrative fines imposed, equal to the lesser of one half of an assisted living facility’s biennial license and bed fee or $500.00, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint. 96. | Onor about May 11, 2005, the Agency received a complaint alleging that an employee of the Respondent had raped a resident at the Respondent’s facility. 97. Onor about May 12, 2005, the Agency conducted an initial complaint investigation (CCR # 2005004016) that resulted in the finding that an employee had raped a resident, a violation that was the subject of the complaint. 98. Pursuant to § 400.419(10), Fla. Stat. (2004), such a finding subjects the Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or FIVE HUNDRED DOLLARS ($500.00). 99. The Respondent’s biennial license and bed fee is $323.00. 100. Respondent is therefore subject to a survey of ONE HUNDRED SIXTY-ONE AND 50/100 DOLLARS ($161.50), pursuant to § 400.419(10), Fla. Stat. (2004). WHEREFORE, the Agency intends to impose an additional survey fee of ONE HUNDRED SIXTY-ONE AND 50/100 DOLLARS ($161.50) against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(10), Fla. Stat. (2004). Respectfully submitted this_@7 day of July 2005. ost ZZ. LLL. fian T. Mulligan , Florida Bar ID #4 0676543 Agency for Health Care Administration 525 Mirror Lake Drive, Suite 330L St. Petersburg, Florida 33701 727.552.1439 (office) 727.552.1440 (fax) 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 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: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308; Telephone (850) 922-5873. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7003 1010 0002 4667 1910 on July &7”_, 2005 to: Gene E. Cowles, Registered Agent, Mapleway Community, Inc., 485 Maple Way, Safety Harbor, Florida 34695, and by U.S. Mail to: John Ross, Administrator, Mapleway Community, Inc., 475 Maple Way, Safety Harbor, Florida 34695. EZ ZZ Brian T. Mulligan Copies furnished to: Gene E. Cowles John Ross Brian T. Mulligan Registered Agent Administrator Agency for Health Care Mapleway Community, Inc. | Mapleway Community, Inc. | Administration 485 Maple Way 475 Maple Way 525 Mirror Lake Drive, N. 330L Safety Harbor, FL 34695 Safety Harbor, FL 34695 St. Petersburg, Florida 33701 (Certified U.S. Mail) (U.S. Mail) (Interoffice Mail) PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. _in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. Mapleway Community, Inc. 2005004465 Facility Name AHCA No. SENDER: COMPLET! COMPLETE THIS SECTION ON DELIVERY @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse so that we can return the card to you. § Attach this card to the back of the mailpiece, or on the front If space permits. A. Signature D. Is delivery address different from item 1? CO Yes If YES, enter delivery address below: +] No : — — & _———— KS Noahe Bron? i} Registered rene Receipt for Merchandise) Ranbor ° Cl insured Mall = GOD: ‘ ‘ S4+lA 4. Restricted Delivery? (Extra Fee) O Yes 2, Article Number LO SOS tor om 7003 1010 0002 4¥bb? 1510 220 RS » PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 05-002878