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STATE OF FLORIDA, AGENCY FOR HEALTH CARE _ ADMINISTRATION, Petitioner, vs. : AHCA Case No.: 2006006299 ISLF-WESTCHESTER OF SUNRISE, LLC d/b/a WESTCHESTER OF Leet | Ale 207 Respondent. . / ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against ISLF-WESTCHESTER OF SUNRISE, LLC d/b/a WESTCHESTER OF SUNRISE (THE) (“Respondent”) pursuant io Sections 120.569 and 120.57, Florida Statutes (2005), and alleges: NATURE OF THE ACTION This is multi-count acffon to impose an administrative fine of NINE THOUSAND - DOLLARS wa WESTCHESTER OF SUNRISE pursuant to Sections 400.414, and 400.419(2)(c), Florida Statutes (2005), based upon twelve repeat Class III “deficiencies cited at a survey on or about May 23, 2006, that were each repeated deficiencies from a survey on or about November 12, 2004, and one Class II deficiency; as well as a survey fee in the amount of FIVE HUNDRED DOLLARS ($500.00) against the Respondent, pursuant to Section 400.419(10), Florida Statutes (2005). Page 1 of 59 JURISDICTION AND VENUE 1. This Court has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes (2005). 2. The State of Florida, Agency for Health Care Administration has Jurisdiction over the Respondent pursuant to Chapter 400, Part I, Florida Statutes . (2005). | 3, Venue shall be determined, pursuant. to Chapter 28-106.207, Florida . Administrative Code (2005). . . PARTIES 4. The. AFCA is the enforcing authority with regard to assisted living facility licensure laws pursuant to Chapter 400, Part I, Florida Statutes (2005) and Rule 38A-5, Florida Administrative Code (2005). . 5. Respondent is a 150-bed facility located at 9701 West Oakland Park Blvd., Sunrise, Florida 33351. Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part III, Florida Statutes (2005), and Chapter 58A-5, Florida Administrative Code (2005), having been issued license number 7440, COUNT I THE RESPONDENT FAILED TO ENSURE THA RESIDENT CONTRACTS ARE DATED BY ALL PARTIES VIOLATING Section 400.424(1) and. (5), Florida Statutes (2005) Rule 584-5.024(3)()), Florida Administrative Code (2005) Rule 58A4-5.025(1), Florida Administrative Code (2005) REPEAT. CLASS I DEFICIENCY 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, Page 2 of 59 7. The regulatory provisions of the Florida Statutes and Florida Administrative Code that are specifically pertinent here include the following: SECTION 400.424(1) and (5), FLORIDA STATUTES (2005) 400.424 Contracts.-- (1) The presence of each resident in a facility shall be covered by a contract, executed at the time of admission or prior thereto, between the licensee and the resident or his or her ‘designee or legal representative. Each party to the contract shall be provided with a duplicate original thereof, and the licensee shall keep on file in the facility all such contracts. The licensee may not destroy or otherwise dispose of any such contract until 5 © years after its expiration. : (5) Neither the contract nor any provision thereof relieves any licensee of any requirement or obligation imposed upon it by this part or rules adopted under this part. and RULE 58A-5.024(3)(), Florida Administrative Code (2005) 58A-5.024 Records. , The facility shall maintain the following written records in a form, place and system ordinarily employed in good business practice and accessible to Department of Elder Affairs and Agency staff. . : (3) RESIDENT RECORDS. Resident records shall be maintained on the premises and include: , (i) A copy of the resident’s contract with the facility, including any addendums to the contract, as described in Rule 58A-5.025, F.A.C. and RULE 58A-5.025(1), Florida Administrative Code (2005) 58A-5.025 Resident Contracts. (1) Pursuant to Section 429.24, F.S., each resident or the residents legal representative, shall, prior to or at the time of admission, execute a contract with the facility which. contains the following provisions: ; (a) A list of the specific services, supplies and accommodations to be provided by the facility to the resident, including limited nursing and extended congregate care services if the facility is licensed to provide such services. (b) The daily, weekly, or monthly rate. (c) A list of any additional services and charges to be provided that are not included in ; . the daily, weekly, or monthly rates, or a reference to a separate fee schedule which shall be attached to the contract. (d) A provision giving at least 30 days written notice prior to any rate increase. (e) Any rights, duties, or obligations of residents, other than those specified in Section 429.28, F.S. Page 3 of 59 (f) The purpose of any advance payments or deposit payments and the refund policy for such advance or deposit payments. (g) A refimd policy which shall conform to Section 429,24(3), FS. (h) A written bed hold policy and provisions for terminating a bed hold agreement if a facility agrees in writing to reserve a bed for a resident who is admitted to a nursing home, health care facility, or psychiatric facility. The resident or responsible party shall notify the facility in writing of any change in status that would prevent the resident from returning to the facility. Until such written notice is received, the agreed upon daily, weekly, or monthly rate may be charged by the facility unless the resident’s medical condition, such as the resident’s ‘being comatose, prevents the resident from giving written notification and the resident does not have a responsible party to act in the resident’s behalf. . (i) A provision stating whether the organization is affiliated with any religious organization, and, if so, which organization and its telationship to the facility. (j) A provision that, upon determination by the administrator or health care provider that the resident needs services beyond those the facility is licensed to provide, the resident or the resident's representative, or agency acting on the resident’s behalf, shall be notified in writing that the resident must make arran gements for transfer to a care setting that has services needed by the resident. In the event the resident has no person to represent him, the facility shall refer the resident to the social service agency for placement. If there is disagreement regarding the appropriateness of placement, provisions as outlined in Section 429.26(8), F.S., shall take effect, 8. On November 12, 2004, AHCA conducted a survey of the Respondent’s facility. The standard that resident contracts are to be dated by all parties was not met as follows: Based on record review and interview, the facility failed to ensure that each resident's - record includes a signed contract. The findings include: During the Resident Records Standards portion of the survey, it was noted that 4 out of 11 resident contracts reviewed did not have facility and/or resident signatures. The Administrator was interviewed and after investigation, confirmed the findings. 9. The Respondent was provided a mandated correction date of December 12, 2004. 10. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. The standard that the Respondent failed to ensure that the resident contract is dated by all the parties is again not met. Page 4 of 59 11. On that date, based on a record review and interview with administrative staff, the facility failed to ensure that all residency contracts are dated by both parties upon admission for 4 of 9 resident records reviewed (residents #4, 5, 6 and 7) The findings are: During the Resident Records Standards portion of the survey conducted on 05/23/2006 at — approximately 10 AM, a review of residents contracts noted that 4 of the resident “Admission Agreement Signature Page” of the contracts lack the date that the contract was executed on behalf of the resident and/or the facility as required. During the exit conference conducted at approximately 7:00 PM on the day of the survey, the Administrator acknowledged the findings. 12. The Respondent was provided a mandated correction date of June 22, 2006, 13. The foregoing violations are cited as a repeat deficiency pursuant to Sections 400.424(1) and (5), Florida Statutes (2005), and Rules 58A-5.024(3)() and 58A-5,025(1), Florida Administrative Code (2005), which tequire the Respondent to ensure that resident contracts are dated by both parties. 14, Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents. 15. Pursuant to Section 400.419(2)(c), Florida Statutes, Class II violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count I. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count I; Page 5 of 59 2, Impose a fine in the amount of $500.00 for the referenced violation; and 3, Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the’ violation the subject of the complaint, Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4, Enter other legal or equitable relief as this Court may find appropriate. COUNT II THE RESPONDENT FAILED TO HAVE A RESIDENT RECORD WHICH MUST INCLUDE A WEIGHT RECORD INITIATED ON ADMISSION VIOLATING Rule 58A-5.0181(2)(a)1 through 8, Florida Administrative Code (2005) REPEAT CLASS II DEFICIENCY 16. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 17, The regulatory provisions of the Florida Administrative Codes that are specifically pertinent here include the following: Rule 58A-5.0181(2)(a)1 through 8, Florida Administrative Code (2005) 58A-5.0181 Residency Criteria and Admission Procedures. (2) HEALTH ASSESSMENT. (a) The medical examination report completed within 60 days prior to the individual’s admission to a facility pursuant to Section 429.26(4), F.S., shall address the following: 1, The physical and mental status of the resident, including the identification of any health-related problems and functional limitations; 2, An evaluation of whether the individual will require supervision or assistance with the activities of daily living; 3. Any nursing or therapy services required by the individual; 4. Any special diet required by the individual; Page 6 of 59 | 5. A list of current medications prescribed, and whether the individual will require any assistance with the administration of medication; 6. Whether the individual has signs or symptoms of a communicable disease which is likely to be transmitted to other residents or staff: 7. A statement that in the opinion of the examining physician or ARNP, on the day the examination is conducted, the individual’s needs can be met in an assisted living facility; and . ‘ 8. The date of the examination, and the name, signature, address, phone number, and license number of the examining physician or ARNP. The medical examination may be conducted ‘by a currently licensed physician or ARNP from another state. (b) Medical examinations completed after the admission of the resident to the facility must be completed within 30 days of the date of admission and must be recorded on the Resident Health Assessment For Assisted Living Facilities (ALF), ACA, Form 1823, January 2006, which is incorporated by reference. A faxed copy of the completed form is acceptable, A copy of AHCA Form 1823 may be obtained from the Agency Central Office or its website at hitp://ahca.myflorida.com DOBRA. Previous versions of this form completed up to six (6) months after 7-30-06 are acceptable. (c) Any information required by paragraph (a) that is not contained in the medical examination report conducted prior to the individual’s admission to the facility must be obtained by the administrator within 30 days after admission using AHCA Form 1823. (d) Medical examinations of residents placed by the department, by the Department of Children and Family Services, or by an agency under contract with either department must be conducted within 30 days before placement in the facility and recorded on AHCA Form 1823 described in paragraph (b). (e) An assessment that has been conducted through the Comprehensive, Assessment, Review and Evaluation for Long-Term Care Services (CARES) program may be substituted for the medical examination requirements of Section 400.426, E.S., and this rule. (f) Any orders for medications, nursing, therapeutic diets, or other services to be provided or supervised by the facility issued by the physician or ARNP conducting the medical examination may be attached to the health assessment. A physician may attach a do-not-resuscitate order for residents who do not wish cardiopulmonary resuscitation to be administered in the case of cardiac or respiratory arrest. ~ (g) A resident placed on an temporary emergency basis by the Department of Children and Family Services pursuant to Section 415.105 or 415.1051, F.S., shall be exempt from the examination requirements of this subsection for up to 30 days. However, a resident accepted for temporary emergency placement shall be entered on the facility’s admission and discharge log and counted in the facility census; a facility may not exceed its licensed capacity in order to accept a such a resident. A medical examination must be conducted on any temporary emergency placement resident accepted for regular admission. 18, On or about November 12, 2004, AHCA conducted a survey of the Respondent’s facility. Page 7 of 59 19. Based on record review and interview, 2 out of 11 resident records examined did not contain all of the required information on the medical examination’ form (Health Assessment Form). The findings include: “During the Residency & Admission Criteria portion of the survey, it was revealed: "1. Resident #6's Health Assessment Form lacked documentation of the resident's medication mode, the printed name, Florida license number & address of the health care provider who completed the health assessment and the date that the form was completed. 2. Resident #4's Health Assessment Form (dated 12/08/00) lacked documentation of the the resident's medication mode. : The Administrator was interviewed and after investi gation, confirmed the findings, 20, The Respondent was provided a mandatory correction date of December 12, 2004. 21. On or about May 23, 2006, AHCA conducted .a survey of the Respondent’s facility. Based on record review and interview, the facility failed to ensure that all resident records contain all of the required information on the medical examination form (Health Assessments) for 3 out of 9 resident records reviewed (residents 5, 6 & 9). The findings include: During the Residency & Admission Criteria portion of the survey conducted on 05/23/2006 at approximately 10 AM, the following was noted- 1. During a review of Resident #5's Health Assessment dated 01/09/2004, it was noted that there was neither documentation of an evaluation of the residents Activities of Daily Living (ADL) nor a statement by the resident's health care provider stating that the resident's needs can be met in an ALF as required. 2. During a review of Resident #6's health assessment dated 11/07/2005 anda review of Resident # 9's Health Assessment dated 04/1 8/2006, it was noted that both assessments lack a statement from the examining health care provider verifying that the residents’ needs can be met in an ALF as required. Page 8 of 59 During the exit conference conducted at approximately 7 PM on the day of the survey, the Administrator acknowledged the findings. ‘ 22, The Respondent was provided’a mandated correction date of June 22, 2006. 23, The Respondent failed to ensure that all residents have addressed in their respective medical examination reports the following: (1) physical and mental status of the resident, including the identification of any health-related problems and functional limitations, (2) an evaluation whether the individual will require supervision or assistance with activities of daily living, (3) any nursing or therapy services required by the individual, (4) any special dict required by the individual, (5) a list of current medications prescribed, and whether the individual will require assistance with the adminisiration of medication, (7) whether the individual has signs or symptoms of a communicable disease which is likely to be transmitted to other residents or staff, (7) a statement that in the opinion of the examining physician or ARNP, on the day the examination is conducted, the individual’s needs can be met in an assisted living facility, and (8) the date of the examination, the name, signature, address, phone and license number of the examining physician or ARNP. (The examination may be conducted by a currently licensed physician or ARNP from another state.) These failures constitute a violation of Rules 58A-~5.0181(2)(a)1 through 8, Florida Administrative Code (2005). 24, Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents. 25. + Pursuant to Section 400.419(2)(c), Florida Statutes, Class II] violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for Page 9 of 59 each violation, Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED'DOLLARS ($500.00) for Count 11. COUNT REPEAT CLASS nT DEFICIENCY 26, AHCA Te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 27. The regulatory provision of the Florida Administrative Code that is specifically pertinent here includes the following: RULE 584-5.0181 (2)(4), Florida Administrative Code (2005) 58A-5.0181 Residency Criteria and Admission Procedures. (2) HEALTH ASSESSMENT, (d) Medical examinations of residents Placed by the department, by the Department of Children and Family Services, or by an agency under contract with either department tmust be conducted within 30 days before placement in the facility and tecorded on AHCA Fon 1823 described in paragraph (b), : Page 10 of 59 28. On November 12, 2004, AHCA conducted a survey of the Respondent's “facility. The standard that the Respondent’s administrator failed to obtain ‘missing medical examination information within 30 days of admission was not met based on tecord review and interview. The Respondent failed to obtain missing resident medical information within 30 days after the resident's admission using DOBRA Health Assessment Form 1823 for 2 out of 11 resident records, The findings include: During the Residency & Admission Criteria portion of the survey, it was noted that 2 out of 1] resident records reviewed did not have complete Health Assessments. The 2 residents have been in the facility for more than 30 days. The following information that remains missing after 30 days: ~No Health Assessment date (resident #6) -No medication mode (residents #6 & #7) -No printed name, address and Florida license number for the Health Care Provider completing the Health Assessment (resident #6) The Administrator was interviewed and after investigation, confirmed the findings. » 29, The Respondent was provided a mandated correction date of December 12, 2004, 30. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. The standard that the Respondent failed to have its Administrator obtain missing medical examination information within 30 days of admission is again not met. 31. On that date, based on record review and interview, the facility failed to ensure that any information not contained in the medical examination report (Health Assessment) is obtained by the Administrator within 30 days after admission for 3 out of 9 resident records reviewed (residents 5,6 & 9). Page 11 of 59 The findings inchude: During the Residency & Admission Criteria portion of the Survey conducted on 05/23/2006 at approximately 10.AM, it was noted that information not contained in the Medical examination report (Health Assessment) and not obtained by the Administrator within 30 days after admission was: { 1. During a review of Resident #5's Health Assessment dated 01/09/2004, it was noted that there was neither documentation of an evaluation of the residents Activities of Daily Living (ADL) nora statement by the tesident's health care Provider stating that the resident's needs can be met in an ALF as required, ; 2. During a review of Resident #6's Health Assessment dated 11/07/2005 and a review of Resident # 9's health assessment dated 04/1 8/2006, it was noted that both assessments lack a statement from the examining health care provider verifying that the residents' needs can be met in an ALF as required, During the exit conference conducted at approximately 7 PM on the day of the survey, the Administrator acknowledged the findings, : 32, The Respondent was provided a mandated correction date of June 22, 2006, 33. The foregoing violations are cited as a Tepeat deficiency pursuant to Rules 98A-5.0181(2)(d), Florida Administrative Code (2005), which require the Respondent’s Administrator to obtain. missing medical examination information within 30 days of , WHEREFORE, AHCA demands the following relief: Page 12 of 59 1. Enter factual and legal findings as set forth in the allegations of Count II; 2. Impose a fine in the amount of $500.00 for the Teferenced violation; and 3, Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint, Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT IV THE RESPONDENT FAILED TO HAVE A RESIDENT RECORD WEOCH. MUST INCLUDE A WEIGHT RECORD INITIATED ON ADMISSION VIOLATING Rule 584-5,01 85(6)(a), Florida Administrative Code (2005) REPEAT CLASS I DEFICIENCY 36. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 37. The regulatory provision of the Florida Administrative Code that is specifically pertinent here includes the following: Rule 58A-5.0185(6)(a), Florida Administrative Code (2005) 58A4-5.0185 Medication Practices. Pursuant to Sections 429,255 and 429.256, F.S., and this tule, facilities holding a standard, limited mental health, extended congregate care, or limited nursing services license may assist with the self-administration or administration of medications to residents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule... (6) MEDICATION STORAGE AND DISPOSAL. Page 13 of 59 (a) In order to accommodate the needs and preferences of residents and to encourage residents to remain as independent as possible, residents may keep their medications, both prescription and over-the-counter, in their possession both on or off the facility premises; or in their rooms or apartments, which must be kept locked when residents are _ absent, unless the medication is in a secure place within the rooms or apartments or in some other secure place which is out of sight of other residents. However, both prescription and over-the-counter medications for residents shall be centrally stored if: 1. The facility administers the medication; 2. The resident requests central storage. The facility shall maintain a list of all | medications being stored pursuant to such a request; 3. The medication is determined and documented by the health care provider to be hazardous if kept in the personal possession of the person for whom it is prescribed; 4. The resident fails to maintain the medication in a safe manner as described in this paragraph; ; 5. The facility determines that because of physical arrangements and the conditions or habits of residents, the personal possession of medication by a resident poses a safety hazard to other residents; or. : 6. The facility’s rules and regulations require central storage of medication and that policy has been provided to the resident prior to admission as required under Rule 58A- 5.0181, F.A.C, 38. On or about November 12, 2004, AHCA conducted a survey of the Respondent’s facility. 39. Based on observation and interview, the Respondent failed to ensure that residents’ medications kept in the residents! rooms are kept locked or in a secure place which is out of sight of other residents. The findings are: During the initial tour of the facility while accompanied by the Administrator and two surveyors, the following medications were observed unsecured & visible and/or easily accessible to other residents in double-occupied resident rooms: - 3 bottles of Tylenol . 2 bottle of Robitussin - 2 bottles of Milk of Magnesia, with an expiration date of 02/2003 . Oral analgesic paste with benzocaine, with an expiration date of 01/1999 . Sucrets sore throat lozenges, with an expiration date of 09/1994 . Hydrocortisone cream 1%, with an expiration date of 05/1999 . Triamcinolone 0.1% cream . Systane lubricant eye drops . Neosporin 10. Polysporin 11. Analgesic cream WAmAnIAMN PWN r Page. 14 of 59 The Administrator was interviewed and after investigation, confirmed the findings. 40. The Respondent was provided a mandatory correction date of December 12, 2004. 41. On or about May 23, 2006, AHCA conducted a survey of the Respondent’s facility. Based on observation and interview, the Respondent failed to ensure that all resident medications, both prescription and over-the-counter, kept in the resident's room or apartment, must be kept locked when the resident is absent unless the -medication is in a secure place which is out of sight of other residents. The findings include: During the Initial Tour of the facility on 05/23/2006 at approximately 11.AM , it was observed by 2 (two) surveyors that two (2) resident room doors were completely open and unsecured medications- both over-the-counter and prescription- were in full view of anyone passing by the rooms and looking in. Resident rooms 422 and 556. The medications noted were: . * Room 422- Ipratropium Bromide 0.02% solution Albuterol Sulfate 2.5 mg Peroxide Room 556- Deep Sea Nasal Spray (prescription label on bottle) Clindamycin Phosphate Pledgets 1% Zovirax Ointment 5% (expired 1997) The Administrator was interviewed on 05/23/2006 at approximately 7 PM and after investigation, confirmed the findings. 42. . The Respondent was provided a mandated correction date of June 22, 2006. 43. The Respondent failed to ensure that all resident medications, both prescription and over-the-counter, kept in the resident's room or apartment, must be kept Page 15 of 59 . locked when the resident is absent unless the medication is in a secure place which is out of sight of other residents, These failures constitute a violation of Rules SB8A- ) 5.0185(6)(a), Florida Administrative Code (2005). ‘44, Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the feclity’s residents, , 45. . Pursuant to Section 400.419(2)(c), Florida Statutes, Class II violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation, Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count IV, . WHEREFORE, AHCA demands the following relief: 1, Enter factual and legal findings as set forth in the allegations of Count IV; 2. Impose a fine in the amount of $500.00 for the referenced violation; and 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover’ the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT V THE RESPONDENT FAILED TO COMPLY WITH THE RESIDENT BILL OF RIGHTS VIOLATING Section 400.428(1) Florida Statutes (2005) Page 16 of 59 REPEAT CLASS Il DEFICIENCY 46. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 47. The regulatory provision of the Florida Statutes that is specifically pertinent here includes the following: SECTION 400.428(1), FLORIDA. STATUTES (2005) 400.428 Resident bill of rights,-- (1) 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 of a facility shall have the right ta: (a) Live ina safe and decent living envirahment, free from abuse and neglect, (b) Be treated with consideration and respect and with due recognition of personal dignity, Individuality, and the need for privacy. (c) Retain and use his or her own clothes and other personal Property tn his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facllity can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents, (d) Unrestricted private communication, including recelving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. at a minimum. Upon request, the facility shall make Provisions to extend visiting hours for caregivers and out-of-town guests, and In other simitar situations, (@) Freedom to Participate in and benefit from community services and activities and to achieve the highest Possible level of Independence, autonomy, and interaction within the community. (f) Manage his or her financial affalrs unlass the resident or, If applicable, the resident's representative, designee, surrogate, guardian, or attorney in fact authorizes the administrator of the facility to provide Safekeeping for funds as Provided in s. 400.427, (g) Share a room with his or her spouse if both are residents of the facility. (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular-and frequent intervals except when prevented by inclement weather, Page 17 of 59 (i) Exercise civil and religious liberties, including the right to Independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, . shall be imposed upon any resident, . (i) Access to adequate and appropriate health care consistent with established and recognized standards within the community. . (k) At least 45 days’ notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents. In the case of a resident who has been adjudicated mentally incapacitated the guardian shall be given at least 45 days' notice of a nonamergency relocation or residency termination. Reasons for relocation shall be set forth in writing. In order ' for a facility to terminate the residency of an individual without notice ‘as Provided herein, the facility shall show good cause in a court of competent jurisdiction, , (1) Present grievances and recommend changes In policies, procedures, and services ta the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the residents! exercise of this right. This right Includes access to ombudsman volunteers and’ advocates and the right to be a member of, to be active in, and to associate with advocacy or special! Interest groups. 48. On November 12, 2004, AHCA conducted a survey of the Respondent’s facility. Based on observation and interview, the facility failed to comply with the Resident Bill of Rights to ensure an environment that treats the residents with Tespect and dignity and is safe for the residents. The findings include: During the initial tour of the facility on 11/12/2004, it was observed that there were 3 signs directed to the residents on the walls of the facility. The signs stated: Resident congregate area on first floor- “It shall be unlawful for any person to feed or cause to be fed or leave foodstuffs for consumption by any wild duck within the city limits, except within fifteen (15) feet ofa canal, lake or waterway. Your cooperation will be appreciated. Thank you, " Door in residents’ congregate area- : . "Please keep this door closed at all times, Thank you." Residents’ Library- "Please return mic & set to the library. Thank you activities" Page 18 of 59 It was also noted that audio/visual equipment was on the floor in the library projecting out from the wall creating a potential fall hazard for the residents, A large housekeeping cart was noted in a residents’ hallway not in a comer or up against a wall creating a potential fall hazard for the residents. Finally, a chair on the residents’ patio was observed to have a broken leg, but appeared still in use, The Administrator was interviewed and after investigation, confirmed the findings. 49. The Respondent was provided a mandated correction date of December 12, 2004. 50. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. The Respondent failed to comply again with the Resident Bill of Rights to ensure an environment that treats the residents with respect and dignity and is safe for the residents, 51. On that date, based on observation and interview, the facility failed to comply with the Resident Bill of Rights- the right to a safe living environment and to be given a 45-day notice of relocation by the facility, The findings include: During the initial tour of the survey conducted on 05/23/2006 at approximately 11 AM, it was observed by the two surveyors on the tour that a number of empty resident rooms The Nurse's Station is located directly off the main resident congregate area. The front door of the station opens onto resident congregate area with a lot of observed ‘foot! traffic. Outside the station and to the left of the station's door, it was observed that resident supplies were piled and not secured away from the resident congregate area. Noted were walkers, a commode chair with one leg shorter than the other 3 and an empty Page 19 of 59 medication storage bin. Some of the items extended beyond the station wall and created a potential fall hazard for the residents. , The emergency 'pull-cord’ in the Ladies Room located on the second floor for resident and visitor use was noted to be tied to the prab bar and not easily accessible to anyone who may have fallen and could not get up. A large moving dolly was noted in the former public phone cubical located on the first floor directly adjacent to the main reception area and the main resident congregate area. During the Resident Records portion of the survey, a review of resident contracts noted that the contact states, "The term of this agreement shall be for a period of one month beginning with the date of this agreement and shall be automatically renewable for additional periods of 30 days unless either party gives written notice of termination 30 days prior to the renewal date." During a further review of the resident records, it was noted that the records lack documentation of an addendum specifying that the facility must give all applicable residents a 45-day notice of termination of residency as mandated by the Resident Bill of Rights. ; The Administrator was interviewed on 05/23/2006 at approximately 7 PM, and after investigation, confirmed the findings. 52. The Respondent was provided a mandated correction date of June 22, 2006. 53° The foregoing violations are cited as a repeat deficiency pursuant to Sections 400.428(1), Florida Statutes (2005), which requires the Respondent to comply with the Resident Bill of Rights to ensure an environment that treats the residents with respect and dignity and is safe for the residents. 54. Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents. 55. . Pursuant to Section 400.419(2)(c), Florida Statutes, Class II violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count V. Page 20 of 59 WHEREFORE, AHCA demands the following relief 1. Enter factual and legal findings as set forth in the allegations of Count V; 2. Impose a fine in the amount of $500.00 for the referenced violation; and 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation: the subject of the’ complaint. Assessment of the $500.00 survey fee is ) demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT VI THE RESPONDENT FAILED TO ENSURE THAT FULL BED RAILS ARE NOT USED UNLESS THE RESIDENT IS A HOSPICE RESIDENT VIOLATING Rule 584-5.0182(6)(h), Florida Administrative Code (2005) REPEAT CLASS Il DEFICIENCY 56. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 57. The regulatory provision ‘of the Florida Administrative Code that is specifically pertinent here include the following: Rule 58A4-5.01 82(6)(b), Florida Administrative Code (2005) 384-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (6) RESIDENT RIGHTS AND F ACILITY PROCEDURES. (h) Pursuant to Section 429.41, F.S., the use of physical restraints shall be limited to half- bed rails, and only upon the written order of the resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s Tepresentative. Any Page 21 of 59 458, On or about November 12, 2004, AHCA conducted a survey of the 59. Based on observation, interview and record review, the Respondent failed residents reviewed. The findings include: During the initial tour of the facility while accompanied by the Administrator and two surveyors, the following was identified- interviewed and after investigation, confirmed the findings, The findings include: During the initial tour of the facility conducted on 05/23/2006, at approximately 11:00 , the 2 surveyors on the tour observed full-bed tails in place on both sides ofa Page 22 of 59 bed. The PDA confirmed that the resident is incapable of removing and/or avoiding the restraints without assistance, During an interview with the facility's Resident Care Coordinator at approximately 11:50 AM on the day of the survey, it was revealed that the resident with the full-bed rails is not a Hospice patient. During the exit conference conducted at approximately 7:00 PM on the day of the survey, the Administrator acknowledged the findings, “62, The Respondent was provided a mandated correction date of June 22, 2006, 63. The Respondent based on observation and interview failed to follow regulatory guidelines for the utilization of physical restraints in that fall bedrails are not used unless the Resident is a hospice resident, These failures constitute a violation of Rules 584-5 .0182(6)(h), Florida Administrative Code (2005). 64. Said violations constitute the grounds for the j imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, 65. Pursuant to Section 400.419(2)(c), Florida Statutes, Class In violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation, Therefore, the Agency is authorized te impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count VI. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count VI; 2, Impose a fine in the amount of $500.00 for the referenced violation; and 3. Assess a survey fee of $500.00 in accorilance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the Page 23 of 59 subject of the complaint. Assessment of the $500.00 survey fee is demanded in this-count and the other counts of this complaint contingent upon it being assessed only once, \ 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT VII THE RESPONDENT FAILED TO ENSURE THAT THE PHYSICAL PLANT IS FREE OF DIRT AND DEBRIS AND STRONG AND FOUL ODORS VIOLATING R. 584-5.023(1)(b)., Florida Administrative Code (2005) REPEAT CLASS II DEFICIENCY 66. AHCA Te-alleges and incorporates paragraphs (1).through (5) as if fully - set forth herein. 67. The regulatory provision of the Florida Administrative Code that is specifically pertinent here includes the following: Rule 58A-5.023, Florida Administrative Code Tepair, Appliances may be disabled for safety reasons provided they are functionally available when needed, 68. On November 12, 2004, AHCA conducted a survey of the Respondent's facility. The standard that the Respondent physical plant is free of dirt and debris free of strong and foul odors, and in good repair is not met. Based on observation and interview, the facility failed to ensure that the facility's physical structure is clean and in good repair. Page 24 of 59 The findings include: During the initial tour of the facility, it was observed that in resident room #528, the door and doorjamb to the bathroom was dirty with the paint worn away. It was also observed that the baseboard and wall paper in the bathroom was pulling away from the wall. Again, it was noted that the baseboards throughout the entire 2nd floor are in need of cleaning and repainting. The Administrator was interviewed and after investigation, confirmed the findings. .69, The Respondent was provided a mandated correction date of December 12, 2004, 70. AFCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. The standard that the Respondent physical plant is free of dirt and debris, free of strong and foul odors, and in good repair is again not met. The findings include: stored under the counter in the bathroom. Three vents just below the windows in the atrium were noted to have large areas of dirt approximately in a 3 X 2.5 foot area located directly underneath the vents. Two large garbage bags filled with trash were noted unsecured in a resident haliway by the laundry room door. The Administrator was interviewed on 05/23/2006 at approximately 7 PM and after investigation, confirmed the findings, 71. - The Respondent was provided a mandated correction date of June 22 2 2006. 72. The foregoing violations are cited as a repeat deficiency pursuant to Rules 58A-5.023(1)(b), Florida Administrative Code (2005), which requires the Respondent’s physical plant is free of dirt and debris, free of strong and foul odors, and in good repair. Page 25 of 59 73. Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents. 74. Pursuant to Section 400.419(2)(c), Florida Statutes, Class ID violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count VIL WHEREFORE, AHCA demands the following telief: ; 1. Enter factnal and legal findings as set forth in the allegations of Count VIL 2. Impose a fine in the amount of $500.00 for the referenced violation; and 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT Vint THE RESPONDENT FAILED TO ENSURE THAT PEELING PAINT OR WALLPAPER IS REPAIRED AND STAINED CEILING TILE REPLACED VIOLATING Rule 58A-5.023(1)(b), Florida Administrative Code (2005) REPEAT CLASS DY DEFICIENCY 75. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. Page 26 of 59 76. The regulatory provision of the Florida Administrative Code that is specifically pertinent here include the following: - Rule 58A-5,023, Florida Administrative Code 58A-5.023 Physical Plant Standards, (1) GENERAL REQUIREMENTS... : (b) The facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair. Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. . Windows, doors, plunibing, and appliances shall be fictional and in good working order, All furniture and furnishings shall be clean, finctional, free-of-odors, and in good repair. Appliances may be disabled for safety reasons provided they are functionally available when needed, . 77, On November 12, 2004, AHCA conducted a survey of the Respondent’s facility. The standard that the Respondent physical plant is free of peeling paint and wallpaper, stained ceiling tiles replaced and in good repair is not met. Based on observation and interview, the facility failed to ensure that peeling paint or wallpaper is repaired or replaced. The findings include: During the tour of the facility, the 3 surveyors noted that the wall paper in many areas of the facility was water stained. For example, the wallpaper above the entry door to - The Administrator was interviewed and after investigation, confirmed the findings. 78. The Respondent was provided a mandated correction date of December 12, 2004. -79. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. The standard that the Respondent physical plant is free of peeling paint and wallpaper, stained ceiling tiles replaced and in good repair is not met is again not met. Based on observation and interview, the facility failed to ensure that peeling Page 27 of 59 wallpaper is repaired in one of the residents’ shared bathrooms and a stained ceiling tile is replaced. The findings include: During the initial tour of the facility on 05/23/2006 at approximately 11 AM, it was noted by 2 surveyors that in the residents’ and visitors' shared Ladies bathroom on the second floor, a large section of peeling and torn wallpaper was observed by the commode grab bar. The peeling/torn section is approximately 3 feet long by 10" wide. Ina large meeting room on the second floor, it was noted that the large ceiling tile surrounding the chandelier was badly stained. The Administrator was interviewed on 05/23/2006 at approximately 7 PM and after investi gation, confirmed the findings. 80. The Respondent was provided a mandated correction date of June 22, 2006. 81. The foregoing violations are cited as a repeat deficiency pursuant to Rules 58A-5,023(1)(b), Florida Administrative Code (2005), which requires the Respondent's physical plant is free of peeling paint and wallpaper, stained ceiling tiles replaced and in good repair. 82. _. Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, 83. Pursuant to Section 400.419(2)(c), Florida Statutes, Class II violations are subject to an administrative fine of not Jess than $500.00 and not exceeding $1,000.00 for each violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count VII, WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count VID; Page 28 of 59 2. Impose a fine in the amount of $500.00-for the referenced violation; and 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as anthorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint, Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT IX THE RESPONDENT FAILED TO ENSURE THAT ALL APPLIANCES , DOORS AND PLUMBING ARE FUNCTIONING AND IN GOOD WORKING ORDER : VIOLATING Rule 58A-5.023(1)(b), Florida Adininistrative Code (2005) REPEAT CLASS UI DEFICIENCY 84, AHCA re-alleges and incorporates paragraphs (1) throngh (5) as if fully set forth herein. 85. The regulatory provision of the Florida Administrative Code that is specifically pertinent here includes the following: Rule 584-5.023, Florida Administrative Code (2005) 58A-5.023 Physical Plant Standards. (1) GENERAL REQUIREMENTS... (b) The facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair. Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. Windows, doors, plumbing, and appliances shall be functional and in good working order. All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. Appliances may be disabled for safety reasons provided they are functionally available when needed. . 86. On November 12, 2004, AHCA conducted a survey of the Respondent’s Page 29 of 59 facility. The standard that doors, plumbing and appliances at the Respondent’s physical plant are functional and in good working order. Based on observation and interview, the facility failed to ensure that doors and plumbing are in good working order, The findings include: ! During the initial tour of the facility, it was observed that the door knob to the Women's shared bathroom on the first floor was loose. Also, the toilet seats in both the Women's aud Men's shared bathrooms on the first floor were unsecured creating a potential fall hazard for the residents, , The Administrator was interviewed and after investigation, confirmed the findings. 87. The Respondent was provided a mandated correction date of December 12, 2004. 88. AHCA surveyors conducted a survey of the Respondent's facility on or about May 23, 2006. Based on observation and interview, the Respondent failed again to ensure that all appliances in resident congregate areas are functional and in good working order. One ceiling light fixture has 7 of 18 bulbs non-operational and another ceiling light fixture has 10 of 18 bulbs non-operational. The findings include: During the initial tour of the facility conducted on 05/23/2006 at approximately 11 AM, it was noted that a number of light bulbs in the two large chandeliers located in the foyer 89. The Respondent was provided a mandated correction date of June 22, , 2006. 90. The foregoing violations are cited as a repeat deficiency pursuant to Rules 58A-5.023(1)(b), Florida Administrative Code (2005), which requires the doors, Page 30 of 59 ' plumbing and appliances of Respondent’s physical plant are functional and in good. working order. | 91. Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened ‘the physical. or emotional health, safety or security of the facility’s residents. ) . 92. Pursuant to Section 400.419(2)(a), Florida Statutes, Class I violations are subject to an adminisirative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count LX, WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count IX; 2. Impose a fine in the amount of $500.00 for the referenced violation; and 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT X THE RESPONDENT FAILED TO ENSURE THAT ALL DOORS AND FASTENING DEVICES ARE SECURE AND IN GOOD WORKING ORDER ; _ VIOLATING Rule 58A-5.023(1)(b), Florida Administrative Code (2005) REPEAT CLASS II DEFICIENCY Page 31 of 59 93. AHCA re-alleges and incorporates Paragraphs (1) through (5) as if fully set forth herein. 94. The regulatory provision of the Florida Administrative Code that is specifically pertinent here inciudes the following: Rule 584-5.023, Florida Administrative Code _ 58A-5.023 Physical Plant Standards, (1) GENERAL REQUIREMENTS... (b) The facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair, Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced, Windows, doors, plumbing, and appliances shall be functional and in good working ; order, All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. Appliances may be disabled for safety reasons provided they are functionally available when needed. . 95. On November 12, 2004, AHCA conducted a survey of the Respondent’s facility, Based on observation and interview, the facility failed to ensure that the facility's furniture and furnishings are clean and in good repair. The findings include: 96. The Respondent was provided a mandated correction date of December 12, 2004, 97. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. Based on observation and interview, the Respondent failed to again ensure that all furniture and furnishings are in good repair. Page 32 of 59 ’ The findings include: During the initial tour of the facility on 05/23/2006 at approximately 11 AM, it was noted that a large mirror in resident room 539 was sitting on the floor and leaning against the 98. The Respondent was provided a mandated correction date of June 22, 2006. 99. The foregoing violations are cited as a repeat deficiency pursuant to Rules 58A-5.023(1)(b), Florida Administrative Code (2005), which requires the facility's furniture and furnishings are clean and in good repair, 100. Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s tesidents. 101. Pursuant to Section 400.419(2)(c), Florida Statutes, Class IIT violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count X, WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count X; 2. Impose a fine in the amount of $500.00 for the referenced violation; and 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is Page 33 of 59 demanded in this count and the other counts of this complaint contingent - upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT xr DOCUMENTED ON AN ANNUAL BASIS - VIOLATING oR 58A-5.019(2)(a), Florida Administrative Code (2005) REPEAT CLASS DT DEFICIENCY 102, AHCA Te-alleges and incorporates paragraphs (1) through (5) as if filly set forth herein, 103. The regulatory provision of Florida Administrative Code that is Specifically pertinent here includes the following: Rule 584-5.019(2)(a), Florida Administrative Code (2005) 58A-5.019 Staffing Standards,.., (2) STAFF, ; (a) Newly hired staff shall have 30 days to submit a statement from a health care, provider, based on a examination conducted within the last six months, that the person 104. On November 12, 2004, AHCA conducted a survey of the Respondent’s facility. The standard that the Respondent ensure that its staff are free of tuberculosis documented on an annual basis is not met. Based on record review and interview, the Page 34 of 59 -facility failed to ensure that all personne] files contain documentation of freedom from tuberculosis on an annual basis. The findings include: During the Staff Records Standards portion of the survey, it was noted that 7 out of 8° employee files lacked documentation of an annual statement’from a health care provider verifying that the employees are free from tuberculosis. The Assistant Administrator was interviewed and after investigation, confirmed the findings. _ : ; 105. The Respondent was provided a mandated correction date of December 12, 2004, 106. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. The standard that the Respondent failed to ensure that staff members are free of tuberculosis documented on an annual basis is again not met, Based on record review and interview, the facility failed to ensure that 5 out of 6 staff members are free from tuberculosis, documented on an annual basis (employees #1,2,3,5 & 6). The findings include: During the Staff Records portion of the survey conducted on 05/23/2006 at approximately 10 AM, it was noted that 5 staff records examined do not contain documentation of the staff members’ current TB status (within the past 365 days). The Administrator was interviewed on 05/23/2006 at approximately 7 PM, and after investigation, confirmed the findings. -107. The Respondent was provided a mandated correction date of June 22, 2006. 108. The foregoing violations are cited as a repeat deficiency pursuant to Rules 98A-5.019(2)(a), Florida Administrative Code (2005), which requires the Respondent to ensure that staff members are free of tuberculosis documented on an annual basis. Page 35 of 59 109. Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or Security of the facility’s residents, 110. Pursuant to Section 400.419(2)(c), Florida Statutes, Class II violations are WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count Xq; 2. Impose a fine in the amount of $500.00 for the referenced Violation; and 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint, Assessment of the $500.00 survey fee is. demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4, Enter other legal or equitable relief as this Court may find appropriate, COUNT xn THE RESPONDENT FAILED TO ENSURE THAT ALL EMPLOYEES RECEIVE HIV & AIDS TRAINING WITH UPDATES BIENNIALLY VIOLATING: . Section 400.427(2), Florida Statutes (2005) Rule 584-5.0191 (3), Florida Administrative Code: (2005) Rule 58A-5.024(2)(a)1, Florida Administrative Code (2005) REPEAT CLASS II DEFICIEN Cy lil. AHCA te-alleges and incorporates paragraphs (1) through (5) asif Page 36 of 59 and fully set forth herein, 112. ‘The regulatory provisions of the Florida Statutes and Florida Administrative Code that are specifically pertinent here incinde the following: Section 400.427(2), Florida Statutes (2005) or any of such resident's Property. An owner, administrator, or staff member, or Tepresentative thereof, May not act as a competent resident's Payee for social security, Rule §8A4-5.0191 (3), Florida Administrative Code (2005) S8A-5.0191 Staff Training Requirements and Competency Test... (3) HUMAN IMMUNODEFICIENCY VIRUS/ACQUIRED IMMUNE DEFICIENCY Page 37 of 59 and Rule 58A-5.024(2)(a)1, Florida Administrative Code (2005) 584-5.024 Records. The facility shall maintain the following written records in a form, place and system ordinarily employed in good business practice and accessible to Department of Elder Affairs and Agency staff... : : (2) STAFF RECORDS. (a) Personnel records for each staff member shall contain, at a minimum, a copy ofthe - original employment application with references furnished and verification of freedom from communicable disease including tuberculosis, In addition as applicable: 1. Documentation of compliance with all staff training required by Rule 58A-5.0191, FAC; ° 113. On November 12, 2004, AHCA conducted a survey of the Respondent’s facility. The standard that the Respondent failed to ensure that all of its employees receive HIV and AIDS training with updates biennially. Based on interview and record review, the facility failed to have documentation verifying that all staff members complete biennially a continuing education courses on HIV and AIDS. The findings include: ) During the Staff Records Standards portion of the survey, it was noted that 4 out of the 8 employee files reviewed did not contain current documentation of HIV and AIDS training. The Assistant Administrator was interviewed and after investigation, confirmed the findings. 114. The Respondent was provided a mandated correction date of December 12 > 2004, us. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. The standard that the Respondent failed to ensure that all of its employees receive HIV and AIDS training with updates biennially is again not met. Based on record review and interview, the facility failed to ensure that all employees Page 38 of 59 receive HIV and AIDS training with updates biennially for 4 out of 6 employee records Teviewed (employees #1,3,4 & 6). The findings include: 116. The Respondent was provided a mandated cotrection date of June 22, 2006. 117. The foregoing violations are cited as a repeat deficiency pursuant to Section 400.427(2), Florida Statutes (2005), Rules S8A-5 -0191(3) and 58A-5 -024(2)(a)1, Florida Administrative Code (2005), which require the Respondent to ensure that all employees receive HIV and AIDS training with updates biennially. 118. Said violations constitute the grounds for the imposed repeat deficiency in ° ‘that it indirectly or potentially ‘threatened the physical or emotional health, safety or security of the facility’s residents, 119, Pursuant to Section 400.419(2)(c), Florida Statutes, Class violations-are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation, Therefore, ‘the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count XI, WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count XU; 2. Impose a fine in the amount of $500.00 for the referenced violation; and Page 39 of 59 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that. result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT XUIT THE RESPONDENT FAILED TO ENSURE THAT ALL APPLIANCES , DOORS AND PLUMBING ARE FUNCTIONING AND IN GOOD WORKING ORDER VIOLATING . Section 400.4275(2), Florida Statutes (2005) Rule 58A4-5.024(2)(a)1, Florida Administrative Code (2005) Rule 584-5.0191(4), Florida Administrative Code (2005) REPEAT CLASS Il DEFICIENCY. 120. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 121. The regulatory provisions of the Florida Statutes and Florida Administrative Codes that are specifically pertinent here include the following: Section 400.4275(2), Florida Statutes (2005) 400.4275 Business practice; personnel records; liability insurance.--The assisted living facility shall be administered on a sound financial basis that is consistent with good business practices, .., 2) The administrator or owner of a facility shall maintain personnel records for each staff member which contain, at a minimum, documentation of background screening, if applicable, documentation of compliance with all training requirements of this part or applicable rule, and a copy of all licenses or certification held by each staff who performs services for which licensure or certification is required under this part or rule. Page 40 of 59 ‘and. Rule 58A-5.024(2)(a)1, Florida Administrative Code (2005) 58A-5.024 Records, . ; The facility shall maintain the following written records in a form, place and . system ordinarily employed in good business practice and accessible to Department of . Elder Affairs and Agency staff... and (2) STAFF RECORDS. . (a) Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition as applicable: 1. Documentation of compliance with all staff training required by Rule 58A-5:0191, RAC; 7 , Rule 58A4-5.0191(4), Florida Administrative Code (2005) 58A-5.0191 Staff Training Requirements and Competency Test. (b) A nurse shall be considered as having met the training requirement for First ‘Aid. An emergency medical technician or paramedic currently certified under Part I of Chapter 401, F.S., shall be considered as having met the training requirements for both First Aid and CPR. 122. On November 12, 2004, AHCA conducted a survey of the Respondent’s facility. The standard that Respondent’s appropriate personnel records contain documentation of current certification in approved First Aid and CPR courses is not met, Based on interview and record Teview, the facility failed to ensure that all applicable employees' personnel records contain documentation of current certification in First Aid and CPR, The findings include: During the Staff Records Standards portion of the survey, it was noted that the facility bus driver does not have valid documentation in First. Aid and CPR. An interview with Page 41 of 59 the Administrator and the Business Office Manager reyealed that when the residents leave the facility on the facility's bus, many times the only staff member on the bus is the driver. A review of the bus driver's personnel record (employee #5) noted that the file lacked documentation of current training in First Aid and CPR. The Administrator and the Assistant Administrator were interviewed and after investigation, confirmed the findings. 123. The Respondent was provided a mandated correction date of December 12, 2004. 124. AHCA surveyors conducted a survey of the Respondent’s facility on or about May 23, 2006. Based on observation, record review and interview, the Respondent failed again to ensure that appropriate personnel records contain documentation of ) current certification in approved First Aid and CPR courses, The findings include: During the Staff Records Standards portion of the survey conducted on 05/23/2006 at approximately 10 AM, it was noted that in the facility's van driver personnel record, there is no documentation of current certification in First Aid or CPR. The van driver without the current First Aid or CPR documentation is left in charge of the residents when transporting the residents and no other facility employee is with the residents. The Administrator was interviewed on 05/23/2006 at approximately 7 PM and after investigation, confirmed the findings, 125. The -Respondent was provided a mandated correction date of June 22, 2006. 126. The foregoing violations are cited as a repeat deficiency pursuant to Section 400.4275(2), Florida Statutes (2005), Rules 58A-5.024(2)(a)1 and 58A- 5.0191(4), Florida Administrative Code (2005), which require the Respondent ensure that all appropriate personnel records contain documentation of current certification in approved First Aid and CPR courses. Page 42 of 59 127, Said violations constitute the prounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, — 128. Pursuant to Section 400.419(2)(c), Florida Statutes, Class IM violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for cach violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count XT. WHEREFORE, AHCA demands the following relief: . 1. Enter factual and legal findings as set forth in the allegations of Count ° XIU; 2. Impose a fine in the amount of $500.00 for the referenced violation; and’ 3. Assess a Survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT xIV THE RESPONDENT FAILED TO MAINTAIN AN ACCURATE RECORD OF RESIDENTS RECEIVING LIMITED NURSING SERVICES VIOLATING Rule 58A-5.031(3)(a), Florida Administrative Code (2005) REPEAT CLASS It DEFICIENCY Page 43 of 59 129. AHCA te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 130. The regulatory provision of the Florida Administrative Code that is specifically pertinent here includes the following: Rule 584-5.031(3)(a), Florida Administrative Code (2005) 584-5.031 Limited Nursing Services, Any facility intending to provide limited nursing services as described in subsection (1) must meet the license requirements specified in Section 429.07, F.S., and obtain a license from the Agency in accordance with Rule 58A-5.014, F.A.C.... (3) RECORDS, (a) A record of all residents receiving limited nursing services under this license and the type of service provided, shall be maintained, 131. On or about November 12, 2004, AHCA conducted a survey of the Respondent’s facility. Based on observation, interview and record review, it was determined that the Respondent failed to maintain an accurate tecord of residents Teceiving LNS (Limited Nursing Services) and failed to identify nursing services provided to residents as services meeting LNS criteria. The findings include: recipients of hospice services, The remaining 5 records were chosen as a tesult of Surveyor observation of the current residents, Page 44 of 59 Resident #4 was observed with dressings on both lower legs. Record review indicated that she was currently receiving wound care via a 3rd party provider. Record review wound care by a 3rd party provider dated 9/12/04, There was no documented evidence to indicate that the facility identified this resident as a recipient of LNS services, The review of Resident #10's record revealed that the resident was receiving treatment for @ wound on the left lower leg. Additionally, the record contained a physician's order for the application of Ted hose. Neither treatment was identified by the facility as an LS Service. Resident #11's record indicated that the resident's physician ordered the application of Ted hose on 7/6/04, On 9/17/04, wound care orders were obtained for the treatment of an Open area on the sacrum. Additionally, Resident #11 had a Foley catheter and was on oxygen, neither of which were independently maintained by the resident. 132. The Respondent was provided a mandatory correction date of December 12, 2004, 133. Onor about May 23, 2006, AHCA conducted a survey of the Respondent's facility. Based on record review and interview, the facility failed to identify 2 out of 9 sampled residents as requiring limited nursing services (residents #5 & #9). The findings include:. During the Resident Care Standards portion of the Survey conducted on 05/23/2006 at approximately 10 AM, the following was noted- 1. Review of documentation on the Medication Administration Record (MAR) for Resident #5 noted an order dated 05/22/2006 to," Apply Neosporin with a Band-Aid to right foot once daily for one week.” An interview on the day of the survey at Page 45 of 59 approximately 5:10 PM with the facility licensed practical nurse (LPN) revealed the nurses. do this treatment. An interview with the LPN noted above and the Resident Care Coordinator (same day and same approximate time noted above) revealed the resident had seen their physician on 05/22/06 when the treatment was ordered. The Resident Care Coordinator statéd that they were unaware that the resident should be under LNS. Review of the LNS log for the facility on the day and time of the. survey noted the resident was not listed on the lo Be 2. Review of the nurses notes for Resident #9 revealed the nurse documented on 05/18/2006, the resident has sustained, " large abrasion/skin tear to left elbow atea...covered with non-stick sterile dressing, held in place with stretch sterile dressing." On 05/19/2006, the nurse documented ".,.wound is bleeding...no response from physician...Pressure dressing re-enforced and resident requested to drive his own car (to hospital) in spite of nursing requesting he use the ambulance..." Later, on’ 05/19/06, the nurse documented "Returned to facility. Alert and oriented X 3. Dressing to left forearm and elbow clean, dry and intact...Follow-up with MD in 2 days..." There was no further documentation in the notes and no physician orders for care to the wound. Interview with the Resident Care Coordinator at approximately 2:50 PM and 5:00 PM revealed on the day of the survey, " the dressing is still on (his/her) arm." Review of the LNS log on the day and time of the survey noted that the resident was not listed. Further interview with the Resident Care Coordinator on the day and times noted above revealed that the resident goes to a dialysis center three times a week and the dressing could be changed there, There was no documentation in the clinical record of this. There was no documentation that the facility ensured that the resident followed up with the MD. 134. The Respondent was provided a mandated correction date of June 22, 2006. 135. The Respondent based on record review and interview failed to maintain accurate record of residents receiving Limited Nursing Services. These failures constitute a violation of Rules 5 8A-5.031(3)(a), Florida Administrative Code (2005). 136. Said violations constitute the grounds for the imposed repeat deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents. | 137. Pursuant to Section 400.419(2)(c), Florida Statutes, Class TI violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for Page 46 of 59 each violation. Therefore, the Agency is authorized to impose a fine in the amount of FIVE HUNDRED DOLLARS ($500.00) for Count XIV. WHEREFORE, AHCA: demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count XIV; . , 2. Impose a fine in the amount of $500.00 for the referenced violation; and 3. ‘Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. COUNT XV THE RESPONDENT FAILED TO MAINTAIN A CURRENT AND UP-TO- DATE MEDICATION OBSERVATION RECORD FOR EACH RESIDENT WHO RECEIVES ASSISTANCE WITH SELF-ADMINISTRATION OF MEDICATION ‘ OR MEDICATION ADMINISTRATION VIOLATING Rule 584-5.0185(5)(b), Florida Administrative Code (2005) CLASS I DEFICIENCY 138. AFCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 137. The regulatory provision of the Florida Administrative Code that is specifically pertinent here includes the following: Rule 58A-5.0185(5)(b), Florida Administrative Code (2005) 58A-5.0185 Medication Practices. Page 47-of 59 Pursuant to Sections 429.255 and 429.256, F.S., and this rule, facilities holding a standard, limited mental health, extended congregate care, or limited nursing services license may. assist with the self-administration or administration of medications to residents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule.... (5) MEDICATION RECORDS.... . : (b) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each: medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time themedication is offered or administered. 138. Onor about May 23, 2006, AHCA surveyors conducted a survey of the Respondent’s facility that resulted in a Class I deficiency. The standard that the Respondent shall maintain a current and up-to-date MOR for each resident who receives assistance with self-administration of medications or medication administration is not met as evidenced by the survey. Based on record.review and interview, the facility failed to maintain a valid and up-to-date Medication Observation Record (MOR) for 2 out of 9 tesidents' MORs reviewed and directly threatened the physical health and safety of the residents (residents #1 & &). The findings include: During the Medication Standards portion of the survey while accompanied by the Resident Care Coordinator on 05/23/2006 at approximately 3:55 PM, the following discrepancies were identified: 1. Resident #1 MOR (May 2006) entry- Labetalol HCL 100 mg, take one tablet twice daily Medication bottle label- Labetalol HCL 200 mg, take one tablet by mouth twice daily 2. Resident #8 MOR (May 2006) entry- Prednisone 7.5 mg, take one tablet once per day Medication bottle label- Prednisone 5 mg, take 2 tablets every other day. Page 48 of 59 During the exit conference conducted on 05/23/2006 at approximately 7:00 PM, the Administrator acknowledged the findings. 139. For this Class II deficiency, AHCA provided the Respondent a mandated correction date of June 22, 2006. 140. The foregoing violation is cited as a Class II deficiency pursuant to Rule 58A-5.0185(5)(b), Florida Administrative Code (2005), which requires the Respondent to maintain a current and up-to-date MOR for each resident who receives assistance with self-administration of medications or medication administration. 141. Such violations constitute the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety or security of the facility’s residents other than a Class I violation, pursuant to Section 400.419(2)(b), “Florida Statutes (2005). WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count XV; 2. Impose a fine in the amount of $1,000.00 for the referenced violation; 3. Assess a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once, 4. Enter other legal or equitable relief as this Court may find appropriate. _ COUNT XVI | Page 49 of 59 THE RESPONDENT FAILED TO MAINTAIN A CURRENT AND UP-TO- DATE MEDICATION OBSERVATION RECORD FOR EACH RESIDENT WHO RECEIVES ASSISTANCE WITH SELF-ADMINISTRATION OF MEDICATION OR MEDICATION ADMINISTRATION . VIOLATING Rule 58A-5.0185(6)(b)2., Florida Administrative Code (2005) CLASS 1 DEFICIENCY 142, AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 143. The regulatory provision of the Florida Administrative Code that is specifically pertinent here includes the following: Rule 58A-5.0185(6)(b)2., Florida Administrative Code (2005) 58A-5,0185 Medication Practices. Pursuant to Sections 429.255 and 429.256, F.S., and this rule, facilities holding a standard, limited mental health, extended congregate care, or limited nursing services License may assist with the self-administration or administration of medications to tesidents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule. ; (6) MEDICATION STORAGE AND DISPOSAL, (b) Centrally stored medications must be: 2, Located in an area free of dampness and abnormal temperature, except that a medication requiring refrigeration shall be refrigerated. Refrigerated medications shall be secured by being kept in a locked container within the refrigerator, by keeping the refrigerator locked, or by keeping the area in which refiigerator is located locked; 144. On or about May 23; 2006, AHCA surveyors conducted a survey of the Respondent's facility that resulted in a Class II deficiency. The standard that the Respondent shall ensure that centrally stored medications must be kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times, as well as, the securing of refrigerated medication must be kept in locked containers within the refrigerator, by keeping the refrigerator locked, or keeping the area in which the refrigerator is located locked is not met as evidenced by the survey. Based on observation and interview, the facility failed to ensure that all centrally stored Page 50 of 59 medications are properly secured at all times which directly threatens the physical health and safety. of the residents. The findings include: During the initial tour of the facility on 05/23/2006 at approximately 11 AM, it was ‘observed that the facility's Medication Room is located next to the main resident congregate area, the resident dining room and the resident congregate lobby area. The 2 surveyors observed the Medication Room door open and unattended. Upon entering the Medication Room, one surveyor observed the keys to the medication cart sitting | unsecured on the Nurse's station desk and showed the’keys to the other surveyor. Further observation noted the following prescription and over-the-counter medications sitting unsecured also on the desk and easily accessible to anyone entering the unsecured area: 1. Folic Acid 2. Furosemide Crestor 3. Seroquel 4. Metolazone 5. Rhinocort Aqua 6. Xanax ‘ 7. Imdur 8. Norvasc During a later observation at approximately 12:45 PM, the surveyors observed the Medication Room again unlocked and unattended with multiple medications again unsecured and easily accessible. At approximately 3:50 PM the surveyors observed the medication cart sitting in the main resident common area near the medication room and it was noted to be unlocked and unattended. with the keys hanging from the lock. Approximately 5 medications were observed sitting unsecured on top of the medication cart. During a later observation on the day of the survey at approximately 4:12 PM, it was noted that multiple medications were again left on top of the medication cart unsecured . and unattended. It was noted that the medication cart was again left unlocked. During the éxit conference conducted at approximately 7:30 PM on the day of the survey, the Administrator acknowledged the findings. 145. For this Class II deficiency, AHCA provided the Respondent a mandated correction date of June 22, 2006. 146. The foregoing violation is cited as a Class Il deficiency pursuant to Rule 58A-5.0185(6)(b)2., Florida Administrative Code (2005), which requires the Respondent Page 51 of 59 shall ensure that centrally stored medications must be kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times, as well as, the securing of refrigerated medication must be kept in locked containers within the refrigerator, by keeping the refrigerator locked, or keeping the area in which the refrigerator is located locked. 147. Such violations constitute the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety or security of the facility’s xesidents other ‘than a Class I violation, pursuant to Section 400.419(2)(b), Florida Statutes (2005). WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Count XVI; 2. Impose a fine in the amount of $1,000.00 for the referenced violation; 3. ASSESS a survey fee of $500.00 in accordance with Section 400.419(10), Florida Statutes (2005), as authorized to cover the cost of conducting initial complaint investigations that result in finding of the violation the subject of the complaint. Assessment of the $500.00 survey fee is demanded in this count and the other counts of this complaint contingent upon it being assessed only once. 4. Enter other legal or equitable relief as this Court may find appropriate. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Make factual and legal findings in favor of the Agency on Counts I through XVI; Page 52 of 59 2. Impose fines respectively as follows for Counts I through XVI: Counts I through XIV: $ 500.00 for each Count ; and Counts XV and XVI: $ 1,000.00. for each Count. 3. The total of fines requested to be imposed on all Counts is NINE THOUSAND DOLLARS ($9,000,00). 4, Assess asurvey fee of FIVE HUNDRED DOLLARS ($500.00) 5. The sum total of all fines and fee sought is NINE THOUSAND FIVE HUNDRED DOLLARS ($9,500.00) 6. Enter other legal and equitable relief as may be appropriate, NOTICE The Respondent, ISLF-WESTCHESTER OF SUNRISE, LLC d/b/a WESTCHESTER OF SUNRISE (THE), 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 ont 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 the Agency for Health Care Administration, Attn: Richard Shoop, Agency Clerk, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida 32308. THE RESPONDENT IS FURTHER NOTIFIED, IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. Submitted this ./9- _dayof__ Se et: 2006. Page 53 of 59 Eric R. Bredemeyer AHCA - Assistant Gerneral Counsel Fla. Bar No.: 318442 2295 Victoria Ave,, Room 346C Fort Myers, Florida 33901 Office: (239) 338-3203 Fax: (239) 338-2699 CERTIFICATE OF SERVICE I HEREBY CERTIFY that one original Administrative Complaint has been sent via certified mail return receipt requested to Administrator, WESTCHESTER OF SUNRISE (THE), 9701 West Oakland Park, Blyd., Sunrise, FL 33351 (return receipt # 20lo(3/0000337/404 1 7 ), and via certified mail return receipt requested to SPECTOR, GADON & ROSEN, LLP, REGISTERED AGENT for WESTCHESTER OF SUNRISE, LLC d/b/a WESTCHESTER OF SUNRISE (THE), 360 Central Avenue, Suite 1550, St. Petersburg, FL 33701 (return receipt # Doblod/oosoo 239/4e494), on this \2 day of Seat 2006. Eric R. Bredemgyst, Esquire Copy to: Diane Reiland, Field Office Manager West Palm Beach Field Office Page 54 of 59

Docket for Case No: 06-003907