STATE OF FLORIDA O6 MAR ~3 Pp} AGENCY FOR HEALTH CARE ADMINISTRATION a STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2005008010 2005008842 Petitioner, V. SENIOR LIVING/LAKE MARY, LLC, d/b/a GABLES OF LAKE MARY, THE, O (g . QO 1 G y Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against SENIOR LIVING LAKE MARY, LLC, d/b/a THE GABLES OF LAKE MARY (hereinafter Respondent), pursuant to Section 120.569, and 120.5 7, Fla. Stat., (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $20,000.00 based upon Respondent being cited with two State Class I deficiencies pursuant to §400.419(2)(a) Fla. Stat. (2005). JURISDICTION AND VENUE l. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). 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 federal regulations, state statutes, and rules governing assisted living facilities pursuant to the Chapter 400, Part II, Florida Statutes, and; Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates al02-bed assisted living facility located at 3655 W. Lake Mary Blvd., Lake Mary, Florida 32746, and is licensed as an assisted living facility, icense number 10007. 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 (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, no resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident ofa facility shall have the right to, inter alia, live in a safe and decent living environment, free from abuse and neglect, and to be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. Section 400.428(1), Fla. Stat. (2005). 8. That on June 14-17, 2005, the Agency conducted a Complaint Survey of the Respondent. 9. That based upon observation, interview, and the review of records, the Respondent facility failed to ensure that one sampled resident was protected from medical neglect and tN physical abuse and that the privacy rights of all residents in the facility receiving care and services from nursing staff were respected and protected. 10. That resident number three resided on the Respondent’s Alzheimer's locked unit and had been diagnosed with Alzheimer's disease. 11.‘ That the Petitioner’s representative interviewed Respondent’s staff member number three on June 17, 2005 who communicated the following: a. b. That the staff member was a direct caregiver for resident three; That the staff member reported that resident number three often complained of pain in the side; That the staff member had noticed that the resident was losing weight and was not eating; That the staff member noticed the body of resident number three was limp on the evening of June 8, 2005; That the staff member, in the presence of another caregiver, reported the resident’s condition to a nurse of Respondent; That the Respondent’s nurse informed the staff member that the resident was just impacted; That the staff member had reviewed the June 2005 bowel monitoring sheet for resident number three; That the resident’s bowel monitoring sheet was annotated in its entirety with zeros indicating that the resident had had no bowel movements in the month of June; That the staff member felt that resident number three should be sent to the hospital; j. That the staff member was told by nursing staff that the family had to make that decision; k. That the staff member felt that should the staff member call 91 1, he/she would be "chewed out". 12, That the Petitioner’s representative interviewed Respondent’s staff member number nine on June 16, 2005 who communicated the following: a. That the staff member had often heard resident number three complain of constipation and yelling “Help me! Help me!” b. That the staff member had observed resident number three as always wanting to go to the bathroom. 13. That the Petitioner’s representative interviewed Respondent's staff member number ten on June 17, 2005 who communicated the following: a. That resident number three was found by staff member number six on the evening of June 9, 2005; b. That staff member number six contacted staff member number ten; c. That the resident was observed with shallow breathing and brown emesis discharging from both the mouth and nose; d. That neither staff member attempted to do cardio-pulmonary resuscitation due to the fact that the resident had a charted Do Not Resuscitate (DNR) order; e. That staff member ten had told the Respondent’s nurse about the fact that the resident was constipated but the nurses would just say, "I know, I know"; f That the resident later expired on June 9, 2005. 14. That the Petitioner’s representative interviewed a local law enforcement officer on June 15, 2005 who communicated that four of Respondent’s staff had been interviewed by law enforcement regarding an allegation that resident number three had been hit with a pillow in the upper body by respondent’s staff member number one, who had been suspended by the Respondent facility for three days following the incident. 15. That the Petitioner’s representative reviewed the Respondent’s records regarding staff member number one on June 15, 2005. 16. That staff member number one’s personnel records contained no indicia of an incident in which the staff member struck resident number three with a pillow. 17. That the Petitioner’s representative interviewed Respondent’s administrator on June 15, 2005 who communicated the following: a. That the administrator was aware of resident number three having been stricken with a pillow by staff member number one; b. That a different employee had reported that staff member number one was taking resident number three back to the resident’s room after a meal when the resident began crying out in a loud tone of voice; c. That the employee stated that resident number three was struck in the upper part of the body with a pillow by staff member number one in an attempt to quiet the resident; d. That staff member number one was suspended from work for three (3) days as a result of the incident; e. That the Respondent’s Director of Nursing (DON) was made aware of the incident; f That staff member one denied the incident had occurred when confronted by the administrator; g. That the staff member who witnessed the incident decided not to report the incident to the abuse hotline; h. That the administrator and the DON also decided not to report the incident to the abuse hotline. 18. That the administrator could produce no documentation to reflect that the facility had investigated the incident. 19, That the administrator would not give the name of the staff member making the allegation of and witnessing the pillow incident. 20. That staff member one continued to be employed at the facility, and was observed working on the Alzheimer's unit throughout the two (2) days of the survey. 21. That the Petitioner’s representative interviewed Respondent’s staff member number nine on June 16, 2005 who communicated the following: a, That the staff frequently put resident number three in his/her room alone and closed the door when the resident was agitated and yelling out; “b. That "...things had changed since the present DON was hired;" c. That the DON was indifferent to residents; d. That in one case, a resident was observed to cry because the DON repeatedly refused to change the resident's dressing and kept putting the resident off until the resident became so frustrated he/she began to cry; e. That another resident had very frail skin; f That Respondent’s certified nursing assistant (CNA) assigned to care for the resident did not take care in transferring the resident out of bed; g. That the CNA pulled the resident out of bed by the arms, causing skin tears to the forearms of the resident. 22. That the Petitioner’s representative observed the second floor nurses’ station at 12:45 PM on June 15, 2005 and noted the following: a. That the nurse practitioner was on duty with another facility staff person; b. That a resident seated in a wheelchair was observed receiving treatment to the lower body area at this time; c. That a small baby identified as belonging to the nurse practitioner was observed in the exam room behind the nurses' station; d. That the nurses' station was observed to be located across from an elevator from which people were observed to be entering and exiting. 23. That the Petitioner’s representative confidentially interviewed a resident on June 15, 2005 who communicated the following: a. That the resident believed resident privacy rights were not being protected; b. That when the nurse practitioner visited the facility once a week, the nurse practitioner would not visit individual residents' rooms; c. That residents had to go to the nurses' station for treatment as the nurse practitioner had a baby and did not want to leave the nurses’ station; d. That the private health issues had to be discussed at the nurses’ station within earshot of other residents and staff members; e. That the resident’s private health concerns were being discussed openly and these health concems provided sources of gossip for staff members and residents. 24. That the above reflects that the Respondent facility failed to ensure that the residents of the facility were free from medical neglect and abuse and that the resident’s privacy rights were not protected in the facility’s allowance of treatment and health consultations to take place in an open hallway. 25. That the Agency determined that this violation constitutes the grounds for the imposition of a Class I deficiency in that it presents 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. Pursuant to Section 400.419(2)(a), Florida Statutes (2004). 26. That the Agency provided the Respondent with a mandatory correction date of June 18, 2005. 27. That on August 24, 2005, the Agency completed a re-visit to the complaint survey of the Respondent. 28. That based upon observation, interview and record review, the facility failed to ensure that one (1) sampled resident in a sample of ten (10) was protected from medical neglect in the Respondent’s failure to follow physician’s orders regarding the monitoring of blood pressure. The resident ultimately suffered a cardio vascular accident with high blood pressure and was admitted to a rehabilitation center for continued care and therapy in violation of law. 29. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number seven on August 22, 2005 which reflected the following: a. That the resident’s health assessment form 1823 dated May 25, 2005 documented the medical history as "N/A" (not applicable ) and listed the resident as independent with ambulation, dressing, toileting, eating grooming, transferring and needed assistance with bathing; That the resident’s assessment included special diet instructions for a regular diet and there were no listed medications. The form indicated "n/a" regarding assistance or supervision of medications; That a nurses note dated May 20, 2005 at 12:00 "resident admitted to floor, oriented, ambulating well accompanied by relatives, blood pressure 160/79, temperature 98.8, weight 142 Ibs"; That a physician's order dated May 25, 2005 "for blood pressures to be checked 3 times a week and to call the physician if the readings were greater than 140/90;" ‘That a nurses note dated May 25, 2005 (time not indicated) "Advanced Registered Nurse Practitioner (ARNP) gives new orders to do blood pressures 3 times a week noted"; That a nursing note dated August 12, 2005 at 1710 provided "patient examined at this time per [her/his] request, blood pressure 197/102, pulse 90, speech noted to be slurred with mild confusion noted, possible CVA/TIA, American Ambulance picked up the resident and took them [sic] to the hospital"; That the Respondent’s resident records, including the Medication Observation Records (MOR), contained no evidence that the orders for blood pressure checks 3 times a week were noted and acted upon or that the facility staff was even aware of the order, with the exception of the nurse who wrote the note dated May 25, 2005; That the Respondent’s resident records contained no indicia that the Respondent followed through or conducted any of the ordered monitoring of the resident’s blood pressure. 30. That the Petitioner’s representative reviewed the resident’s records maintained at the rehabilitation center where resident was admitted on August 19, 2005 following the resident’s hospitalization which reflected the following: a. That history and physical hospital admission examination dated August 12, 2005 documented resident number seven’s blood pressure as 164/93 mmHg with an assessment of Expressive aphasia and Systolic hypertension (high blood pressure); That the resident’s Patient Transfer and Continuity of Care (form 3008) signed and dated by the physician on August 19, 2005 gave as the principle diagnosis "1. CVA (Cerebrovascular Accident) with aphasia, 2. Hypertension (HTN), 3. A- Fibs with CVR and failed swallow study." Medications and treatment orders on the 3008 were for "nectar thick liquids & puree diet assist with meals, sit upright to eat and drink, no straws, crush pills in apple sauce. No ice, ice cream, Jell-O or soup, alternate liquids with solids. Boost (dietary supplement) and pudding BID (twice daily), ASA (aspirin) 325 mg daily Catapres TS (antihypertensive) 0.1 mg weekly Lexapro (antidepressant) 10 mg daily and PT (physical therapy) to evaluate and treat and recommended Skilled Nursing (ECF) Duration”; That Physicians Admission Orders, in addition to those listed in above, ordered "Speech Therapy to do vital stimulation and ASPIRATION PRECAUTIONS;’ That the rehabilitation center Resident Admission-Data Form listed diagnoses as CVA with aphasia, Hypertension, A- Fibs with CVR. The resident's care plan dated August 22, 2005 documented that the resident required extensive/total assist with bed mobility, transfer, dressing, eating, personal hygiene and bathing, was at risk for skin breakdown and for aspiration. 10 31. That the Petitioner’s representative interviewed resident number seven on August 24, 2005 who had difficulties speaking and was confused as to the events that caused the admission to the hospital. The resident was dressed, groomed, alert, oriented to self and resting in bed. 32. That the Petitioner’s representative interviewed the Director of Nursing at the Rehabilitation Center on August 24, 2005 who revealed that the resident was currently on Catapress TTS 0.1 mg and the resident's blood pressures are being monitored twice a day. Said medication regime and increased monitoring is indicated as a result of the resident’s recent cardio vascular accident. 33. That the Petitioner’s representative interviewed the Respondent’s administrator on August 22, 2005 who stated that the resident’s nursing note dated May 25, 2005 acknowledging the physician’s order for blood pressure checks had been written by the Respondent’s former director of nursing (LPN) who did not follow-up and who no longer worked at the facility. The administrator gave no indication whether or not the administrator was aware of the order. 34. That the Petitioner’s representative interviewed the Respondent’s licensed practical nurse regarding resident number seven on August 22, 2005 who gave no indication of an awareness of the physician’s order for blood pressure monitoring and would offer only the fact that the nurse was not an employee of Respondent at the time the orders were given. 35. That the Petitioner’s representative interviewed the ARNP who wrote the order for blood pressure monitoring 3 times a week son August 23, 2005 who indicated "That when an order like that was called to the facility it is for the facility to carry out, since the resident was not capable of doing his/her own blood pressure.” 36. That the above reflects the respondent’s failure to ensure that its resident did not suffer from medical neglect and as a result of said medical neglect the resident’s blood pressure was not IH monitored culminating in the resident’s experiencing a cardio vascular accident and subsequent hospitalization. 37. That the agency determined that the above constitutes grounds for the imposition of a Class J deficiency in that it presents 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. 38. That the Respondent has violated the provisions of law regarding resident’s rights by medical neglect and privacy violations as recited herein as cited by the Agency on both its June 17 and August 24, 2005 surveys, said violations presenting present and imminent danger to the residents. 39, That pursuant to Section 400.419(2)(a), Florida Statutes (2005), the Agency is authorized to impose a fine in the amount of ten thousand dollars ($10,000). 40. That the Agency provided the Respondent with a mandatory correction date of August 26, 2005. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(a), Fla. Stat. (2005), COUNT II 41. AHCA re-alleges and incorporates paragraphs (1) through (5) and (7) through (40) as if fully set forth herein. 42. That pursuant to Florida law, no resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of F lorida, or 12 the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to, inter alia, live in a safe and decent living environment, free from abuse and neglect, and to be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. Section 400.428(1), Fla. Stat. (2005). 43. That on September 13, 2005, the Agency conducted a Revisit to the Complaint Survey of the Respondent. 44, That based upon observation, interview, and the review of records, the Respondent facility failed to protect three diabetic residents from medical neglect in violation of law. 45. That the Petitioner’s representative reviewed the Respondent’s records regarding residents numbered one (1), seven (7), and eight (8) on September 13, 2005. 46. That all three residents receive assistance with medications including, but not limited to the monitoring of blood glucose levels and the administration of insulin. 47. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number one (1) which reflected the following: a. That the resident’s medication record for September 2005 reflected that the resident was to receive accu-checks for blood glucose level monitoring once in the morning and once in the afternoon with other accu-checks as needed; b That the resident was to receive the following insulin administrations: Novolin 70/30 100U inject 30U SubQ in the AM Novolin 70/30 100U inject 18U SubQ in the PM; C. That additional insulin coverage was to be administered if the resident's blood sugar levels were in the following ranges: Novolin R 100U Sliding Scale 0-200=0 units(u) 201-300=6 units 301-400=9 units 401-450=12 units Call MD if greater than 450 That the resident’s physician’s order sheet (hereinafter “POS”) signed by the advanced registered nurse practitioner (hereinafter “ARNP”) on August 10, 20005 contained a different ordered sliding scale from that written on the Resident’s September 2005 Medication Record. That the actual sliding scale Ordered for September 2005 was as follows: Novolin R100 Sliding Scale was: 0-200=0 units 201-250=3 units 251-300=6 units 301-400=9 units 401-450=12 units units greater than 12 units call MD That a nurse’s note documented that the resident was transported and admitted to the hospital on Angust 19, 2005 at 2100 as the resident was feeling "Chilly"; That there was no documentation available to reflect if the resident's blood sugar was checked prior to leaving for the hospital or of what the resident was diagnosed with upon admission to the hospital; That the resident was readmitted to the Respondent facility on September 9, 2005; That upon readmission, a telephone order was documented by a registered nurse to discontinue Prilosec, continue Nexium 40mg-continue all previous medications as ordered prior to hospitalization; That the resident’s blood sugar was recorded at two hundred thirty-three (233) at 5PM on September 11, 2005; k. That in accord with the outstanding physician’s order, the resident should have received three (3) units of Novolin R 100U; That the records contained no indication that the resident was administered the ordered insulin; That on September 12, 2005, in accord with the physician’s orders of record, the resident was to be administered 7AM dosages of insulin Novolin 70/30, inject 30U SubQ take in the AM; That the records contained no indication that the resident was administered the ordered insulin. 48. That the petitioner’s representative interviewed the respondent’s director of nursing on September 13, 2005 who indicated the following: a. That the director of nursing completed resident number one’s September 2005 medication observation record; That information for the medication observation record is obtained from the previous month’s physician’s orders; That upon review, the director of nursing acknowledged that there was extant a discrepancy between the September 2005 medication observation record and physician’s orders of record; That perhaps the September 2005 medication administration record had been copied from August 2005 record without checking the current physician’s orders or that another staff member had entered the August 2005 information on the medication administration records with the incorrect information; 15 e. That the director of nursing acknowledged at 4:20 PM that the director of nursing had copied and entered incorrect information on the medication record of September 2005 in regards to the sliding scale of insulin dosages to be administered. 49. That the Petitioner’s representative interviewed Resident number one (1) on September 13, 2005 and noted the following: a. That the resident was alert and oriented; b. That the resident indicated that the resident returned from the hospital on September 9, 2005 and that the resident had been told by family that at the time that the resident was transported to the hospital, the resident was comatose; c. That the resident could not recall anything that occurred in the hospital due to the severity of illness; d. That the resident had, in the past, kept records of the dates and amounts of insulin administered prior to hospitalization but has not done so since readmission due to the resident’s not feeling well; e. That the resident could not recall if the resident’s glucose was high on September 11, 2005 or if regular insulin coverage was administered on September 12, 2005; f. That the resident usually received insulin administrations, though the resident is unaware of the amounts administered. 50. That the Petitioner’s representative interviewed the Respondent's registered nurse on September 13, 2005, who indicated as follows: a. That the nurse worked the 3:00 PM to 11:00 PM shift on September 11, 2005; b. That the nurse was identified as the nurse who had administered the resident’s accu-check on September 11, 2005; Cc. That the nurse sometimes administers insulin to the resident as do other nurses; d. That the procedure utilized is to check the glucose level and, if high, to administer insulin in accord with the sliding scale contained on the medication administration record, and document these activities. 51. That the Respondent’s registered nurse later contacted the Petitioner’s representative on September 13, 2005 and added the following information: a. That the nurse had recalled the administration of insulin to resident number one (1) on September 11, 2005 at 5:00 PM; b. That the nurse had annotated the resident’s medication administration record to reflect the administration of six (6) units of insulin at 5:00 PM on September 11, 2005; c. That the nurse had been informed that the insulin administration on the sliding scale had been incorrect on September 11, 2005 and that the six (6) units administered were not in accord with physician’s orders which would have required only three (3) units; 52. That the Petitioner’s representative reviewed the Respondent’s medication administration record for resident number one (1) after having been informed by the Respondent’s registered nurse of the late entry reflecting an insulin administration on September 11, 2005 and noted the following: a. That the record had since been amended to reflect the administration of insulin; b. That the late entry by the Respondent's registered nurse had been made, but had not been annotated in any mamner to reflect that the entry had not been made contemporaneously with the administration of the medication; c. That the resident’s blood sugar level at 5:00 PM on September 13, 2005 had been annotated at two hundred eighty-six (286); d. That the physician’s order, and the sliding scale entered on the medication administration record, would call for the administration of six (6) units of insulin; e. That the medication record had been annotated to reflect that the resident had been administered three (3) units of insulin. 53. That the above reflects a series of errors constituting medical neglect including, but not limited to, the failure of the Respondent facility to ensure that the medication administration record for resident number one (1) accurately reflected the sliding scale for the insulin required for the resident, the Respondent facility’s improper administration of insulin in accord with that sliding scale even after the record had been corrected, the failure to administer and record the administration of insulin on September 11 and 12, 2005, and the failure of the Respondent’s registered nurse to accurately reflect the nurses treatment of the resident in the resident’s records. 54. That the Respondent’s registered nurse made a late entry to the resident’s record which was not identified as such, that reflected a purported memory that was inconsistent with the physician’s orders on the record at the time of the purported administration and as such would have been a significant medication error. 55. That under either scenario which may be gleaned from the Respondent’s registered murse’s statements and annotations, Resident number (1) was not appropriately treated for a diabetic condition in accord with the prescribed sliding scale of insulin administration. 18 56. That the above facts, individually and collectively, constitute medical neglect of resident number one (1) in violation of law. 57. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number seven (7) which reflected the following: a. That the resident’s medication record for September 2005 reflected that the resident was to receive accu-checks for blood glucose level monitoring once in the morming and once in the afternoon with other accu-checks as needed; That the resident was to receive the following insulin administrations: Novolin N 100U inject 22U SubQ in the AM Novolin N 100U inject 10U SubQ in the PM; That additional insulin coverage was to be administered if the resident’s blood sugar levels were in the following ranges: Humulin R 100U Sliding Scale as follows 0-151=0 U 151-200=2U 201-250=4U 251-300=6U 301-350=8U 351-400=10U Call MD if greater than 400 That the resident’s medication record reflected that the resident’s blood sugar level was one hundred fifty-one on September 1, 2005 at 4:00 PM; That in accord with the prescribed sliding scale, the resident should have been administered two (2) units of insulin; That the medication record was devoid of any indication that the prescribed insulin was administered to the resident; g. That the resident’s medication record reflected that the resident’s blood sugar level was one hundred sixty-three (163) on September 12, 2005 at 7:00 AM; h. That in accord with the prescribed sliding scale, the resident should have been administered two (2) units of insulin; f That the medication record was devoid of any indication that the prescribed insulin was administered to the resident. 58. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number eight (8) which reflected the following: a. That the resident’s medication record for September 2005 reflected that the resident was to receive accu-checks for blood glucose level monitoring four times daily; That the resident was to receive the following insulin administrations: Novolin 70/30 100U inject 47U SubQ in the AM Novolin 70/30 100U inject 20U SubQ in the PM; That additional insulin coverage was to be administered if the resident’s blood sugar levels were in the following ranges: Humulin R 100U Sliding Scale as follows 0-151=0 U 151-200=3U 201-250=5U 251-300=7U 301-350=9U 351-400=11U ; Call MD if less than 60 or greater than 400 That the resident’s medication record reflected that the resident’s blood sugar level was one hundred fifty-four (154) on September 12, 2005 at 7:00 AM; 20 e. That in accord with the prescribed sliding scale, the resident should have been administered three (3) units of insulin; f That the medication record was devoid of any indication that the prescribed insulin was administered to the resident. 59. That the Petition’s representative interviewed resident number eight (8) on September 13, 2005 and noted an alert and oriented individual who does not recall a high blood glucose, with glucose levels not high in the morning, but usually hi gh at lunch time. 60. That the Petitioner’s representative interviewed the Respondent’s nurse identified as the individual who conducted the accu-checks for residents numbered seven (7) and eight(8) who indicated the following: a. That the nurse worked the morning shift on September 12, 2005; b. That she could not recall an accu-check that was high; c. That had a blood sugar reading been high, insulin coverage would have been provided; d. That some residents take medications by mouth. 61. That the above facts, individually and collectively, constitute medical neglect of resident number one (1) in violation of law. 62. That the agency determined that the above constitutes grounds for the imposition of a Class I deficiency in that it presents 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. 63. That the Respondent has violated the provisions of law regarding resident’s rights by medical neglect and privacy violations as recited herein as cited by the Agency on both its June 21 17, August 24, and September 13, 2005 surveys, said violations presenting present and imminent danger to the residents. 64. That pursuant to Section 400.419(2)(a), Florida Statutes (2005), the Agency is authorized to impose a fine in the amount of ten thousand dollars ($10,000). 65. That the Agency provided the Respondent with a mandatory correction date of September 14, 2005. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(a), Fla. Stat, (2005). Respectfully submitted this _/ / day of January, 2006. Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2005). Specific options for administrative action are set out in the attached Election of Rights (two pages) 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 The 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. N tw CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has bee ed by USS. Certified Mail, Return Receipt No. 7003-1010-0002 4667 0982 on January ij , 2006 to: NRAI Services, Inc. Registered Agent, 2731 Executive Park Dr., #4, Weston, FI. 33331 and by U.S. Mail to Julie S. Fernandez, Administrator, The Gables of Lake Mary, 3655 W. Lake Mary Blvd., Lake Mary, FL 32746. Th . Walsh, I, Esq. Copies furnished to: NRAI Services, Inc. Julie S. Fernandez Thomas J. Walsh, I, Esq. Registered Agent Administrator Agency for Health Care Admin. 2731 Executive Park Dr. #4 The Gable of Lake Mary 525 Mirror Lake Drive, 330G Weston, FL 33331 3655 W. Lake Mary Blvd St. Petersburg, FL 33701 (U.S. Certified Mail) Lake Mary, FL 32746 (Interoffice) (U.S. Mail) 23 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. The Gables of Lake Mary 2005008010/ 2005008842 Facility Name ; AHCA No. STATE OF FLORIDA a i AGENCY FOR HEALTH CARE ADMINISTRATION "Fa EP ia es OG EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES AR DR ile (To be used with Election of Rights for Administrative Complaint form — attacheti),) Hey oe ts vy fy st In response to the allegations set forth in the Administrative Complaint issued by the agen gang lVE Health Care Administration (‘AHCA" or “Agency"), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date you receive the Administrative Complaint. Please make your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on the election of rights form. A final order will be entered setting forth the allegations as being deemed admitted and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the final order. OPTION 2. _ If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Complaint.), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. __ If the Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., Respondent's request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts disputed. If you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if all parties agree to it. IF YOU SELECT OPTION 3, PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the right to a hearing, Respondent’s original Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. if the election of rights form with Respondent's selected option is not received by AHCA within twenty-one (21) days from the date of Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint.

Docket for Case No: 06-000793