STATE OF FLORIDA 06 JUN AGENCY FOR HEALTH CARE ADMINISTRATION 13 py hag Diy iS] Al RE AGENCY FOR HEALTH CARE ADM] INSTR SATIY ADMINISTRATION, HEARINGS YE Petitioner, AHCA No.: 2005006186 v. Return Receipt Requested: 7002 2410 0001 4234 5711 MERIDIAN PARK VILLAGE LIMITED 7002 2410 0001 4234 5728 PARTNERSHIP, d/b/a CLASSIC RESIDENCE 7002 2410 0001 4234 5735 BY HYATT AT LAKESIDE VILLAGE, Respondent. , Ole _ 0 f 7 ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Meridian Park Village Limited Partnership, d/b/a Classic Residence by Hyatt at Lakeside Village (hereinafter “Classic Residence by Hyatt at Lakeside Village”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,000 pursuant to Section 400.419, Florida Statutes (2004), for the protection of the public health, safety and welfare and $500 survey fee pursuant to Section 400.419(10), and 400.428(3)(c), Fla. Stat. (2004) JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Palm Beach County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code. 5. Classic Residence by Hyatt at Lakeside Village operates a 60-bed assisted living facility located at 2792 Donnelly Drive, Lantana, Florida 33462. Classic Residence by Hyatt at Lakeside Village is licensed as an assisted living facility license number AL9045, with an expiration date of September 14, 2005. Classic Residence by Hyatt at Lakeside Village was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. w COUNT I CLASSIC RESIDENCE BY HYATT AT LAKESIDE VILLAGE FAILED TO ENSURE THAT A SAFE ENVIRONMENT WAS BEING MAINTAINED FOR RESIDENTS Rule 58A-5.023(1) (a), Florida Administrative Code (PHYSICAL PLANT S'TANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the Re-licensure Survey conducted on 6/23/05 at approximately 9:30 AM and based upon observations made during a tour of the facility, the surveyor determined that the facility did not maintain a safe environment for the residents. 8. The facility has a locked Alzheimer's unit, which at the time of this survey had a census of 20 individuals with severe Dementia and Alzheimer's disease. 9, During a tour of the unit accompanied by the Administrator the following items were noted as present and accessible to these residents: (a) Razors were noted to be present on the dressers/counters of rooms # 3,17,21,22 and 23. (b) Room # 14 had a bottle of Ibuprofen, a bottle of Dulcolax, a tube of Joint Flex Anti-Arthritic cream and a bottle of Hydrogen Peroxide laying out on the dressers and counters of this room. (c) Room # 21 had a package of Imodium, a tube of A&D ointment, a bottle of Tylenol caplets, another bottle of Tylenol tablets, a bottle of Iodine, a tube of Ben-Gay ointment, and a tube of prescription Dovonex ointment laying out on the room counters/dresser. There were also 3 large safety pins present on the room dresser. 10. The above noted findings represent a direct threat to the physical safety and security of the facility residents. The doors to these rooms on the unit were not locked and residents may enter any room and have access to these items at that time. 11. The Administrator during interview, while touring the unit with the surveyor on the date of this survey confirmed these findings. 12. Based on the foregoing, Classic Residence by Hyatt at Lakeside Village violated Rule 58A-5.023(1) (a), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA May assess a survey fee of $500.00 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of 51,000.00 against Classic Residence by Hyatt at Lakeside Village on Count I for one Class Ir violation. Cc. Assess a survey fee of $500.00 against Classic Residence by Hyatt at Lakeside Village, pursuant to Sections 400.419(10), and 400.428(3)(c), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. "RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DHYS OF/ RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSIO THE COMPLAINT AND THE ENTRY OF A FI Tria Lawton-Russell Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52™ Terrace Suite 103 Miami, (305) Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 Bast Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct foregoing has been furnished by U.S. Certified Florida 33166 copy of the Mail, Return Receipt Requested to Winsome McCloud, Administrator, Classic Residence by Hyatt at Lakeside Village, 2792 Donnelly Drive, Lantana, Florida 33462; Meridian Park Village Limited Partnership, 71 South Wacker Drive, Suite 900, Chicago, IL 60606, and to Corporation Service Company, 1201 Hays Street, DM fA 200¢5 Tallahassee, Florida 32301-2525 ria Lawton-Russell STATE OF FLORIDA Oy AGENCY FOR HEALTH CARE ADMINISTRATION & ps "&, fe ion WY RE: Meridian Park Village Limited Partnership, d/b/a AHCA 299500 189y Classic Residence by Hyatt at Lakeside Village ae is ffl cy oy Lf On ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT Aeieidiny le PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. . OPTION ONE (1) Respondent does not dispute the allegations of fact contained in the Administrative Complaint and waives Respondent’s right to object or to be heard. Respondent understands that by waiving Respondent's rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) ___ Respondent does not dispute and Respondent admits the allegations of fact in the Administrative Complaint, but Respondent does wish to be afforded an "informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time Respondent will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3)___—- Respondent does dispute the allegations of fact contained in the Administrative Complaint and Respondent requests a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. 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 you dispute. In order to preserve Respondent’s 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 the 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. If Respondent is interested in discussing a settlement of this matter with the Agency, please also mark and check this block. Ervices, SEND NO PAYMENT NOW -- REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL, RESPONDENT RECEIVES A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address.) Respondent (Licensee) Address: License. No. and Facility Type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: - Agency for Health Care Administration, Attention: Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. Telephone (850) 922-5873. STATE OF FLORIDA pe oy AGENCY FOR HEALTH GARE ADMINISTRATION F Fi f A i g EXPLANATION OF RIGHTS UNDER SEC. 120. 569, FLORIDA STATUTES 13 Py 2 (To be used with Election of Rights for Administrative Complaint form — “att seat ur 6 f In response to the allegations set forth in the Administrative Complaint issuell 59 Rei, balive Agency for Health Care Administration (“AHCA” or “Agency”), Respondent must make one oP 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 of 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 Compiaint. 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. 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. m Complete items 4, 2, and 3; Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse i, 80 ‘that we can return the Card to you, @ Attach this card to the back of the mailpiece, or on the front if space permits. : 1.. Article Addressed to: a 2 \ feb om am D. ts delivery address diffetant from item 1? L'Ves 'i EYES, entér dativery address below: [1 No oad ) ere 7h Souths Locher Ms AiG POO : Ch. py IL GObEOG® 2. Article Number 3, Service Type CrCertiied Mall. £1 Express Mai OO Registared [-Rétum Receipt for Merchandise Oinsurad Mat. Cc. 7002 2440 O00 4234 5723. . & Complete items 1,2, and 3: Also complete -. item 4 if Restricted Delivery is desired) @ Print your name and address‘on the reverse 80 that we can return the card to you. @ Attach this card to the back of the mailplece, or an the front if space permits, 1. Article Addressed to: Ex _ LFV D..18 dellvery addrass differant from item 1? (2) Yas eh HYES, enter delivery ages

Docket for Case No: 06-002047