STATE OF FLORIDA a) £ & AGENCY FOR HEALTH CARE ADMINISTRATION Gop fy a & STATE OF FLORIDA, Nig Misr, 4b, 2 AGENCY FOR HEALTH CARE YEISEY op 4 ADMINISTRATION, hei Gil Mie Petitioner, . vs. Case No. 2006005928 ALLEGIANCE PROPERTIES 1, INC., d/b/a THE COTTAGES OF PORT RICHEY, O Ly 35 Gq O f 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 ALLEGIANCE PROPERTIES 1, INC., d/b/a THE COTTAGES OF PORT RICHEY (hereinafter “Respondent”), pursuant to §§ 120.569 and 120.57, Fla. Stat. (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $5,000.00 and a survey fee in the amount of $500.00, based upon Respondent being cited for one State Class I deficiency pursuant to §§ 429.19(2)(a) and 429.19(10), Fla. Stat. (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 429.07, 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 429, Part I, Fla. Stat., and Chapter S8A-5 Fla. Admin. Code, respectively. 4. Respondent operates a 100-bed assisted living facility located at 5905 Pinehill Road, Port Richey, Florida 34668, and is licensed as an assisted living facility, under license number 5993. 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-5.0182(1)(c), facilities shall offer personal supervision, as appropriate for each resident, including general awareness of the resident’s whereabouts. The resident may travel independently in the community. 8. On or about 03/31/06 the Agency conducted a complaint investigation (CCR# 2006002924) of Respondent facility. 9. Based on record review and interview, the facility failed to have a general knowledge of Resident # 2’s whereabouts on the date of his/her disappearance and death. 10. Record review revealed that Resident # 2 needed supervision with ambulation. 11. Interviews with the Business Office Manager, Administrator Designee, and Department of Children and Families Adult Protective Investigator on 03/31/06 revealed that on 3/21/06, Resident # 2 stated he/she was going to the bank to get money to pay the facility, but had failed to return to the facility for his/her evening medications. 12. The Administrator Designee confirmed that it is the facility policy to notify her when a resident fails to return and that the supervisor failed to do so. w 13. Interview with the Adult Protective Investigator confirmed the resident had died by drowning. 14. 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. 15. | The Agency provided Respondent with a mandatory correction date of 04/03/06. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(a) Fla. Stat., (2006). COUNT II 16. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and seven (7) through fifteen (15) as if fully set forth herein. 17. The Agency conducted an initial complaint investigation (CCR #2006002924) on 03/31/06 that resulted in the finding of a violation that was the subject of the complaint. 18. Pursuant to § 429.19(10), Fla. Stat. (2006), these violations subject Respondent to a survey fee of $500.00. WHEREFORE, the Agency intends to impose an additional survey fee of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Fla. Stat. (2006). Respectfully submitte ay of August 2006. §25 Mirror Lake Drive, 330K St. Petersburg, Florida 33701 (727) 552-1526 (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. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida 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 U.S. Certified Mail, Return Receipt No. 7005 1160 0002 2254 8573 on August Z Z , 2006 to: Allegiance Senior Care, Inc., Registered Agent, Allegiance Properties 1, Inc., d/b/a The Cottages of Port Richey, 6701 Dairy Road, Zephyrhills, Florida 33542, and by U.S. Mail to: Douglas Klinowski, Administrator, The Cottages of Port Richey, 5905 Pinehill Road, Port Richey, Florida 34668. G . Pickett, Esquire Copies furnished to: Allegiance Senior Care, Inc. Douglas Klinowski Gerald L. Pickett, Esquire Registered Agent Administrator Agency for Health Care Allegiance Properties 1, Inc. The Cottages of Port Administration d/b/a The Cottages of Port Richey | Richey 525 Mirror Lake Drive, 330K 6701 Dairy Road 5905 Pinehill Road St. Petersburg, Florida 33701 Zephyrhills, Florida 33542 Port Richey, Florida 34668 | (Interoffice Mail) (U.S. Certified Mail) (U.S. Mail) edt 7 Lee Oe Wadd tape iid ay UNITED STATES. BEA POSTAL SERVICE® Home | Help Track & Confirm Search Results Label/Receipt Number: 7005 1160 0002 2254 8573 Status: Delivered Track & Confinn Enter Label/Receipt Number. Your item was delivered at 12:05 pm on August 31, 2006 in ZEPHYRHILLS, FL 33542. Notification Options Track & Confirm by email Get current event information or updates for your item sent to you or others by email. 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Docket for Case No: 06-003904