OT 25712 _ e™ a> / STATE OF FLORIDA ty “gy AGENCY FOR HEALTH CARE ADMINISTRATION», 4 ky hy Ys, STATE OF FLORIDA, AGENCY FOR Meds ie Hs, HEALTH CARE ADMINISTRATION, nea Bo Ne aS “Wie Petitioner, vs. Case No. 2007005669 M VILLARD, INC., d/b/a PALMETTO GUEST HOME, INC., 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 M VILLARD, INC., d/b/a PALMETTO GUEST HOME, INC. (hereinafter Respondent), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an assisted living facility or, in the alternative, impose an administrative fine of thirty thousand five hundred dollars ($30,500.00) based upon three (3) State Class I deficiencies and one repeat class III deficiency and to impose a survey fee in the sum of five hundred dollars ($500.00) pursuant to §§429.19(2)(a), (2)(c), and (10), Florida Statutes (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 429.07, Florida Statutes (2006). 2. Venue lies pursuant to Florida Administrative 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, Florida Statutes, and Chapter S8A-5 Florida Administrative Code. 4. Respondent operates a 112-bed assisted living facility located at 820 — 5" Street, West, _ Palmetto, Florida 34221, and is licensed as an assisted living facility, license number 5407. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. ‘That pursuant to Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. R. 58A-5.0182, Florida Administrative Code. 9. That on May 18, 2007, the Agency conducted a Complaint Survey (CCR#2007005557) of the Respondent facility. 10. That based upon the review of records and interview, Respondent failed to provide care and services appropriate to meet the needs of one (1) of nine (9) sampled residents in its failure to obtain services of third parties as required by health care providers, the same being contrary to law. 11. That the Petitioner’s representative reviewed on May 18, 2007, the Respondent’s records and the records of third party health care providers for resident number one (1) and noted the following: a. That the resident had been admitted into the Respondent facility on May 1, 2005; b. That the resident’s health assessment dated May 1, 2005 indicated that the resident suffered with diagnoses of “Enlarged Prostate” as well as having a cognitive status of “dementia;” c. That a local home health agency, provided services to the resident documented from September 21, 2006 until discharge on October 23, 2006; d. That the discharge summary from the home health agency, dated October 23, 2006, reflected and documented that the Respondent facility staff was not making appointments for the resident with a dermatologist as recommended by the home health agency provider caring for the resident; e. That the home health agency further documented on October 23, 2006 regarding the resident’s care that “facility staff unwilling to make appointment for patient to see dermatologist;” f. That the Respondent’s facility “Resident Observation Log” documented on October 5, 2006 that a physician “continues to monitor CL facial cyst, has referred to surgeon;” g. That the Respondent’s “Resident Observation Log” further reflects that the resident was sent to the hospital on November 7, 2006, though no explanation or cause of the hospitalization was provided; . That the Respondent’s “Resident Observation Log” further reflects that the resident had an appointment with a specialist on January 11, 2007; That there were no progress notes relating to the resident between December 14, 2006 through January 18, 2007 which would indicate whether the resident saw an intervening health care professional or the above referenced specialist appointment on January 11, 2007 nor any intervening changes in condition, care, or ordered services; That Respondent’s policies and procedures entitled “Health Status Change Policy and Procedure,” undated, did not address the regulatory requirement that a resident’s physician or other health care provider be notified in the event of a change of resident’s condition; . That on January 17, 2007, the resident was admitted to the care of a second home health agency with the diagnosis of “Skin Disorder NOS;” That the second home health agency provider’s communication log contained an undated note documenting “patient with possible basal cell carcinoma on cheek. MD awaiting biopsy until patient has a guardian. [The administrator of the facility] stated she was in the process of getting a court appointed guardian for resident and this was to be completed by 2/9/07, then our nurse was informed it would not be done until 2/16/07. We still have no word as to where this is in the process of getting someone appointed;” . That the second home health agency further documented on a communication log dated February 16, 2007, “situation reported” to an advocacy agency; . That the second home health agency discharged the resident from its care on March 13, 2007 with the notation that the assisted living facility “facilitate guardianship for patient to have surgery due to lesion on left cheek area;” . That the second home health agency further noted in its “Discharge Notification” to Respondent on March 13, 2007 “to facilitate guardianship appointment” and that the resident’s discharge plan was “surgery after guardianship appointed;” . That a court of appropriate jurisdiction appointed an emergency temporary guardian on March 14, 2007 and the resident was transferred to the hospital on March 14, 2007 and admitted into a nursing facility on the same day; . That the resident was admitted to the nursing home with diagnoses documented in the medical record dated March 15, 2007 of facial cancer, ataxia, and facial cellulitis; That the nursing home diagnosis list and physical identified the resident as having “facial cellulitis, squamous cell CA L Cheek” and a nursing progress note of March 14, 2007 that identified the resident as having “facial cellulitis 5 x 7 cm with foul odor;” That a Dermathpathology Report prepared April 16, 2007 documented “skin biopsy, Left Cheek —- well differentiated squamous cell carcinoma;” That a physician order of April 18, 2007 directed “CT Scan of head and facial bones — Large elevated squamous cell cancer of left temple;” . That the CT results from a local hospital indicated the exam was conducted on April 20, 2007 with “CT face with contrast” and conclusion “irregular, lobulated mass seen extracranially adjacent to the left temporal bone and the left zygomatic arch measuring approximately 6 x 1 cm. No associated bone destruction or erosion is observed;” v. That a April 20, 2007 note documented “Lobulated, enhancing soft tissue mass seen extracranially in the left temporal region. No acute intracranial process is identified;” w. That a plastic surgery center referral of April 25, 2007 referred the resident to a local cancer center for evaluation; 12. That due to the failure of the resident to receive dermatological evaluation and diligent efforts to obtain guardianship status for the consent to invasive procedures, resident number one (1) was placed at risk and suffered deterioration of his medical condition which may have been avoided or lessened had prompt care and services been provided. 13. That the Petitioner’s representative interviewed on May 21, 2007, the director of nursing of the first home health agency which provided services to resident number one (1) who confirmed that home health agency’s recorded notes indicating that Respondent “repeatedly was asked to make the dermatological appointment but did not.” 14. That the Petitioner’s representative interviewed the Respondent’s Owner/Administrator on May 18, 2007 who indicated that she had taken the resident to a dermatology appointment in December 2006 but that the physician would not see the resident due to the resident not being able to give consent. 15. That the record indicates that the resident’s dermatology appointment was scheduled for January 11, 2007, and there is no indication as to whether this appointment was kept and such recorded date is contrary to the recollection of the Respondent’s Owner/Administrator. 16. That the records are devoid of clear and timely efforts of the Respondent to comply with the directives of the health care providers of resident number one (1) regarding arranging consultations of a dermatologist for the resident or any effort to obtain guardianship for the resident in order to address the resident’s emergent and noted health concern. 17. That due to the delay in the resident receiving dermatological evaluations and in obtaining guardianship in order that consent could be obtained for surgical procedures, the resident was placed at risk and suffered deterioration to a medical condition which may have been avoided if prompt medical attention had been provided. 18. That these failures are failures of the Respondent to provide care and services, including the failure to ensure physician consultations are conducted and that guardianship services are obtained, which are appropriate to the needs of the resident, such failures being in violation of Florida law. 19. That the Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of the resident, which the Agency determined presented an imminent danger to the resident or a substantial probability that death or serious physical or emotional harm would result therefrom and cited the Respondent for a State Class I deficiency. 20. | The Agency provided Respondent with a mandatory correction date of May 21, 2007 21. That the Respondent has been cited by the Petitioner on previous occasions for the violation of the provisions cited herein as below described. 22. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 23. That based upon the review of records and interview, Respondent failed to provide care and services to meet the needs of the residents for the week of September 4 through 10, 2006 on the 11:00 PM to 7:00 AM shift due a lack of staff to provide supervision of residents. 24. That the Respondent’s facility is large and divided into five (5) separate wings, one of which is a secured unit. 25. That the facility’s census for the week above referenced was seventy-two (72) with twenty (20) residents on the Main wing, nine (9) residents on the East wing, sixteen (16) residents on the secured North wing, ten (10) residents on the Northeast wing, and eleven (11) residents on the Northwest wing. 26. That the Respondent’s staffing schedules reflect the following staffing schedules for the above referenced week on the 11:00 PM to 7:00 AM shift: a. Monday September 4, 2006 — Three (3) employees to serve and monitor five (5) wings, one employee assigned for the Main and East wing, one employee assigned for the North wing, and one employee assigned for the Northwest and Northeast wings; b. Tuesday September 5, 2006 — Three (3) employees to serve and monitor five (5) wings, one employee assigned for the Main and East wing, one employee assigned for the North wing, and one employee assigned for the Northwest and Northeast wings; c. Wednesday September 6, 2006 — One (1) employee to serve and monitor all five (5) wings; d. Thursday September 7, 2006 — Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings; e. Friday September 8, 2006 -- Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings. 27. That the Petitioner’s representative interviewed the Respondent’s administrator on September 12, 2006 who indicated as follows: a. That the facility usually has one (1) employee covering the Main and East wing, one (1) employee covering the Northwest and Northeast wing and two (2) employees covering the North wing; b. That the facility was not short that week because she had covered anyone's shift who did not show up. 28. That the Respondent’s administrator was not shown on the facility’s schedule. 29. That the Respondent planned for staffing patterns which would provide for four (4) personnel to cover the physical expanse of the facility’s care areas on the night shift. 30. That for a sample period of five (5) days the Respondent failed to provide enough appropriate staff to adequately care for and monitor the facility’s census, on each of said dates not even meeting the Respondent’s anticipated staffing pattern needs. 31. That the failure to provide sufficient qualified staff for the care and services of residents and their monitoring is in violation of law. 32. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 33. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 34. That based upon the review of records and interview, the Respondent failed to provide care and services to meet the needs of the residents for the week of October 23 through 29, 2006 on the 11:00 PM to 7:00 AM shift due a lack of staff to provide supervision of residents. 35. That the Respondent’s facility is large and divided into five (5) separate wings, one of which is a secured unit. 36. That the facility’s census for the week above referenced was sixty-two (62) with eighteen (18) residents on the Main wing, eight (8) residents on the East wing, twelve (12) residents on the secured North wing, twelve (12) residents on the Northeast wing, and twelve (12) residents on the Northwest wing. 37. That the Respondent’s staffing schedules reflect the following staffing schedules for the above referenced week on the 11:00 PM to 7:00 AM shift: a. Wednesday October 25, 2006 — Three (3) employees to serve and monitor all five (5) wings; b. Thursday October 26, 2006 — Three (3) employees to serve and monitor all five (5) wings; c. Friday October 27, 2006 — Three (3) employees to serve and monitor all five (5) wings; 10 d. Saturday October 28, 2006 — Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings; e. Sunday October 29, 2006 — Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings. 38. That the Respondent planned for staffing patterns which would provide for four (4) personnel to cover the physical expanse of the facility’s care areas on the night shift. 39. That for a sample period of five (5) days the Respondent failed to provide enough appropriate staff to adequately care for and monitor the facility’s census, on each of said dates not even meeting the Respondent’s anticipated staffing pattern needs. 40. That the failure to provide sufficient qualified staff for the care and services of residents and their monitoring is in violation of law. 41. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 42. That the Agency provided Respondent with a mandatory correction date of November 1, 2006. 43. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. 44. That during a re-visit survey conducted December 27, 2007 the Agency determined that the Respondent had corrected the deficiency. 45. That pursuant to § 429.19(2)(a), Florida Statutes (2006), the Agency is authorized to impose a fine in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for each violation. 46. That the multiple citations for violation of the charged provision of law provide, inter alia, grounds for aggravation of the administrative fine assessed against the Respondent. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2){a), Florida Statutes (2006). COUNT II 47. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. That pursuant to law, the facility shall, as needed by each resident, assist residents in making appointments and remind residents about scheduled appointments for medical, dental, nursing, or mental health services. R. 58A-5.0182(3)(a), Florida Administrative Code. 49. That on May 18, 2007, the Agency conducted a Complaint Survey (CCR#2007005557) of the Respondent facility. 50. That based upon the review of records and interview, Respondent repeatedly failed to assist residents in making medical appointments for one (1) of nine (9) residents in the survey sample, the same being contrary to law. 51. The Agency re-alleges and incorporates paragraphs eleven (11) through fifteen (15) as if fully set forth herein. 12 52. That the home health agency providing services to resident number one (1) in September and October 2006 requested that the Respondent arrange that a dermatological appointment be arranged and conducted for the resident. 53. That there is no indication that the Respondent made any effort to arrange for the medical services advised by the home health care provider of resident number one (1). 54. That these failures include, but are not limited to, the failure to obtain the services of a dermatologist as requested by the home health agency or consulting services of any other health care provider relating to the resident’s identified dermatological concern. 55. That these failures represent an intentional or callous disregard to making necessary medical arrangements of a resident entrusted to the Respondent’s care. 56. That the Respondent’s failure or refusal to arrange for the required medical consultations for resident number one (1) was a factor in the resident’s home health agency discontinuing services. 57. That a note reflects that a physician was monitoring the resident facial cyst dated October 5, 2006, however no documentation reflects any diagnosis, treatment, or follow-up for this alleged monitoring activity other than an order for antibiotic dated January 18, 2007 some three (3) months later after an alleged appointment of January 30, 2007. 58. That the hospitalization noted for the resident is noted for November 7, 2006, but the records are devoid of any indication of the cause of the hospitalization, any diagnosis, treatment, or follow-up from the resident’s hospitalization. 59. That the Respondent was aware of the facial cyst of resident number one (1), however the record is devoid of effective and consistent efforts to have this emergent concern actively monitored by a health care professional after the October 5, 2006 notation and the discharge of 13 the home health agency on October 23, 2006 until a second home health care provider was obtained January 17, 2007. 60. That the Respondent alleged a December 2006 appointment but no records or treatments reflect the same. 61. That the records reflect a January 11, 2007 appointment, but no records or treatments support an assertion said appointment was kept or treatment, diagnosis, or other services provided. 62. That the Respondent’s failures to make dermatological and or other health care appointments placed the resident at risk of and resulted in the deterioration of the resident's medical condition, said failures in violation of law. 63. | The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of the resident, which the Agency determined presented an imminent danger to the resident or a substantial probability that death or serious physical or emotional harm would result therefrom and cited the Respondent for a State Class I deficiency. 64, The Agency provided Respondent with a mandatory correction date of May 21, 2007. 65. That pursuant to § 429.19(2)(a), Florida Statutes (2006), the Agency is authorized to impose a fine in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for each violation WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(a), Florida Statutes (2006). COUNT II 66. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 67. That pursuant to Florida law, every resident of a facility shall have the right to live in a safe and decent living environment, free from abuse and neglect, and be treated with consideration and respect with due recognition of personal dignity...and the access to adequate and appropriate health care consistent with established and recognized standards within the community. Section 429.28(1), Florida Statutes (2006). 68. That on May 18, 2007, the Agency conducted a Complaint Survey (CCR#2007005557) of the Respondent facility. 69. That based upon the review of records and interview, the Respondent failed to ensure that each resident had the right to adequate and appropriate health care for one (1) of nine (9) residents in the survey sample, by failing to ensure prompt medical attention to prevent deterioration of the resident's medical needs. 70. The Agency re-alleges and incorporates paragraphs eleven (11) through fifteen (15) as if fully set forth herein 71. That the Respondent failed to ensure that resident number one (1) received adequate and appropriate health care in the Respondent’s failure to respond to the directives of home health care providers to seek further physician care, in its failure to diligently advise the resident’s health care provider of the resident’s emergent and ongoing medical concern, in its failure to document services which were provided such as an alleged physician’s visit and hospitalization, neither of which were memorialized with any information which would assist current or future care providers in the assessment and treatment of the resident or the resident’s medical condition(s), in the failure to obtain and maintain home health care services after the discharge of the resident of the prior provider due to, in part, the Respondent’s failure to follow treatment recommendations, and in the delay in obtaining guardianship services necessary to effectuate treatment for the resident. 72. That each of the examples, individually and collectively, reflect that the Respondent actions and inactions deprived resident number one (1) of those rights to adequate and appropriate health care guaranteed to the resident by Florida law. 73. The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of the resident, which the Agency determined presented an imminent danger to the resident or a substantial probability that death or serious physical or emotional harm would result therefrom and cited the Respondent for a State Class I deficiency. 74. The Agency provided Respondent with a mandatory correction date of May 21, 2007. 75. That the Respondent has been cited by the Petitioner on previous occasions for the violation of the provisions cited herein. 76. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 77. That based upon observation, the Respondent failed to comply with the Resident Bill of Rights in regards to living in a safe and decent living environment, the same being in violation of law. 78. That the Petitioner’s representative made visual observations of the facility and its environs on September 12, 2006 and noted that in room number twelve (12), there were multiple bottles of unsecured oxygen bottles behind the room door, under the bed and in the closet. 79. That oxygen bottles which are not properly secured present a safety hazard to the facility and its residents due to, inter alia, the high flammability dangers related thereto. 80. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 81. | The Agency provided Respondent with a mandatory correction date of October 12, 2006. 82. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 83. That based upon observation, the Respondent failed to comply with the Resident Bill of Rights in regards to living in a safe and decent living environment and to live free from abuse and neglect with consideration and respect and due recognition of personal dignity, the same being in violation of law. 84. That the Petitioner’s representative toured the Respondent facility and its environs an October 30, 2006 and noted the following: a. That in room number twelve (12), eight (8) large oxygen bottles were found unsecured under the resident's bed, six (6) small bottles were found unsecured next to the resident's chest of drawers, two (2) small bottles were found lying on the floor of the bedroom, and eight (8) small oxygen bottles were found unsecured in the closet; 17 b. That in room number five (5), two large oxygen bottles were found unsecured in the resident's closet; c. That during lunch in the forward dining room of the dementia unit, an aide was observed feeding resident number four (4); d. That while doing so, another demented resident reached for cake, attempting to obtain it; e. That rather than ordering more food for the other interloping resident, the aide feeding resident number four (4) made batting motions with her hand at the randomly observed resident reaching for the cake; f. That the resident's facial expression changed, his/her eyes widening, and s/he recoiled and withdrew his/her hands; g. That the other resident sat and stared as resident number four (4) was fed the cake, keeping his/her hands close to his/her body for some time afterwards; 85. That oxygen bottles which are not properly secured present a safety hazard to the facility and its residents due to, inter alia, the high flammability dangers related thereto. 86. That the slapping at the hands of a resident is not treating the resident with respect for the resident’s dignity. 87. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 88. That the Agency provided Respondent with a mandatory correction date of November 1, 2006. 18 89. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. 90. That during a re-visit survey conducted December 27, 2007 the Agency determined that the Respondent had corrected the deficiency. 91. That pursuant to § 429.19(2)(a), Florida Statutes (2006), the Agency is authorized to impose a fine in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for each violation. 92. That the multiple citations for violation of the charged provision of law provide, inter alia, grounds for aggravation of the administrative fine assessed against the Respondent. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(a), Florida Statutes (2006). COUNT IV 93. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 94. That pursuant to Florida law, facility records must contain an up-to-date admission and discharge log listing the names of all residents and each resident’s date of admission, the place from which the resident was admitted, and if applicable, a notation the resident was admitted with a stage 2 pressure sore; and date of discharge, the reason for discharge, and the identification of the facility to which the resident is discharged or home address, or if the person is deceased, the date of death. Readmission of a resident to the facility after discharge requires a new entry. Discharge of a resident is not required if the facility is holding a bed for a 19 resident who is out of the facility but intends to return pursuant to rule 58A-5.025 F.A.C. Rule 58A-5.024(1)(b), Florida Administrative Code. 95. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 96. That based upon observation and interview with staff, Respondent did not maintain an up-to-date admission and discharge log. 97. That the Petitioner’s representative reviewed Respondent’s Admission Discharge log on September 11, 2006 at 10:00 AM and noted only sixty-five (65) active residents were listed in the book. 98. That the census of the Respondent facility on September 12, 2006 was seventy-two (72), in clear contrast with the Respondent’s admission discharge log. 99. That the Petitioner’s representative interviewed the Respondent’s new owner/Administrator on September 12, 2006 who indicated that she was aware that since the previous administrator left, the paperwork was not being kept up to date and no other data was provided. 100. That the failure to keep an accurate and up-to-date admission discharge log is in violation of law. 101. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility, or to the personal care of Facility residents, and directly threatened the physical or emotional health, safety, or security of the Facility residents. 102. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2006). 103. That the Agency provided a mandated correction date of October 12, 2006. 20 104. That during a re-visit survey conducted October 30, 2006 the Agency determined that the Respondent had corrected the deficiency. 105. That on May 18, 2007, the Agency conducted a Complaint Survey (CCR#2007005557) of the Respondent facility. 106. That based upon the review of records and interview, Respondent failed to maintain an accurate and up-to-date admission and discharge record as one (1) of nine (9) sampled residents cases the log did not specify the location to which the resident was discharged, the same being contrary to law. 107. That the Petitioner’s representative reviewed Respondent’s Admission and Discharge log on May 18, 2007 and noted that resident number one (1) had been discharged from the facility on March 14, 2007, but the only discharge location was "hospital" and did not specify by name or other indication the facility to which the resident had been discharged. 108. That the Petitioner’s representative interviewed the Respondent’s administrator on May 18, 2007 who could voice the specific name of the hospital which the resident was discharged to, but could not explain the failure to maintain the discharge log as required by law. 109. That the failure to keep an accurate and up-to-date admission discharge log is in violation of law. 110. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 111. That the Agency cited the Respondent for a repeat Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2006). 112. That the Agency provided a mandated correction date of June 21, 2007. 21 113. That this constitutes a repeat violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). . COUNT V 114. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 115. The Agency re-alleges and incorporates Counts I, II, II and IV of this complaint as if fully set forth herein 116. That the Agency may revoke any license issued under Part I of Chapter 429 Florida Statutes (2006) for the citation of one (1) or more cited Class I deficiencies, three (3) or more cited Class II deficiencies, or five (5) or more cited Class III deficiencies that have been cited on a single survey and have not been corrected within the specified time period. Section 429.14(1)(e) Florida Statutes (2006). . 117. That the Respondent has been cited with three (3) Class I deficiencies on an Agency complaint survey of May 18, 2007. 118. That the Agency may revoke any license issued under Section 408.815(1)(d), Florida Statutes (2006) for a demonstrated pattern of deficient performance. 119. That the Petitioner re-alleges and incorporates the Administrative Complaint dated April 26, 2007 attached hereto and incorporated herein as attachment “A”. 120. That the Respondent has been cited with three (3) Class I deficiencies and (1) repeat Class III deficiency on an Agency survey of May 18, 2007 and with multiple deficient practices cited within the body of this complaint and its attachment. 121. That based thereon, the Agency seeks the revocation of the Respondent’s licensure as its primary relief. 122. That should the Respondent admit the facts herein by action or inaction, the Petitioner shall enter an Order revoking the Respondent’s. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§ 408.815(1)(d) and 429.14(1)(e) , Florida Statutes (2006). COUNT VI 123. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Counts I, II, I and IV in their entirety as if fully set forth herein. 124. That as a result of the Agency’s complaint investigation on or about May 18, 2007, the Respondent was cited for three Class I deficiencies and a repeat Class III deficiency which were the subject of the complaint. 125. That pursuant to Section 429.19(10), Florida Statutes (2006), AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 429.28(3)(c), Florida Statutes (2006), to verify the correction of the violations. In this case, AHCA is authorized to request a survey fee in the amount of $500.00. 23 WHEREFORE, the Agency intends to impose an additional survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Fla. Stat. (2006). eee submitted this z Bay of May, 2007. “hh . Bat..No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Copies furnished to: Kathleen Varga Facility Evaluator Supervisor 525 Mirror Lake Dr., 4" Fl. St. Petersburg, Florida 33701 24 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: M VILLARD, INC., CASE NO: 2007005669 d/b/a PALMETTO GUEST HOME, INC. ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be an Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. Your Election of Rights must be returned by mail or by fax within twenty-one (21) days of the date you receive the attached Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. If your Election of Rights with your elected Option is not received by AHCA within twenty-one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your night to contest the Agency’s proposed action and a Final Order will be issued. Please use this form unless you, your attorney or your representative prefer to reply in accordance with Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code. PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Phone: 850-922-5873 Fax: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) ____ I admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a Final Order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2)__— I admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)___ I dispute the allegations of fact and law contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3) by itself is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes may be available in this matter if the Agency agrees. License Type: (Assisted Living Facility, Nursing Home, Medical Equipment, Other) Licensee Name: License Number: Contact Person: Name Title Address: Street and Number City State Zip Code Telephone No. Fax No. E-Mail (optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the above licensee. Signature: Date: Print Name: Title: STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2006011010 M VILLARD, INC., d/b/a PALMETTO GUEST HOME, INC., 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 M VILLARD, INC., d/b/a PALMETTO GUEST HOME, INC. (hereinafter Respondent), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the sum of seven thousand dollars ($7,000.00) based upon one cited State Class II deficiency and twelve cited uncorrected State Class III deficiencies pursuant to Section 429.19(2)(b) and (c), Florida Statutes (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 429.07, Florida Statutes (2006). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living EXHIBIT __/ | facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 429, Part I, Florida Statutes, and Chapter 58A-5 Florida Administrative Code, respectively. 4. Respondent operates a 112-bed assisted living facility located at 820 — 5" Street, West, Palmetto, Florida 34221, and is licensed as an assisted living facility, license number 5407. 5. Respondent was at ail times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to law, facilities shall offer personal supervision including ...contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. R. 58A-5.0182(1)(d), Florida Administrative Code. 8. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey ef the Respondent facility. 9. That based upon the review of records and interview, the Respondent failed to take appropriate actions including the contact of enumerated individuals, when there was a significant change in the health status of a resident, the same being in violation of law. 10. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number one (1) on October 30, 2006 and noted as follows: . That an incident report documented that the resident fell and hit her/his head and body on the floor on October 5, 2006 at approximately 8:45 PM; . That the fall was witnessed by a resident assistant who helped the resident to her/his room and applied an ice pack; _ That there is no indication that the resident assistant or other staff called for transport to the hospital, contacted the resident's physician, or contacted the resident’s family member or guardian of this significant change to the resident; . That there was no documentation reflecting that the resident was examined by medical staff on October 6, 2006; . That on October 6, 2006 at approximately 4:30 PM, Respondent documented that the resident’s daughter had been contacted and informed that the resident was being transported to the hospital for swollen hands; That the record is devoid of any indicia that the resident’s daughter was informed of the resident’s fall; . That the record is devoid of any indicia that the resident’s daughter was informed of the resident’s potential head injury or bruising; . That at the emergency room the resident was treated for a head injury, and the resident given a "cat scan" with serious injury ruled out; That the resident returned to the Respondent facility around midnight; That on October 7, 2006 the resident’s daughter visited the resident and had the resident returned to the emergency room because the resident's feet were badly swollen; k. That the resident’s daughter informed Respondent that the resident would be going to another facility upon discharge from the hospital and the resident currently resides at a local nursing home. 11. That the failure to contact family and medical personnel after a significant change including a resident fall and associated bruising is in violation of law and deprived the resident’s professional and personal caretakers of the opportunity to address such significant events. 12. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 13. . That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2006). 14. The Agency provided Respondent with a mandatory correction date of November 1, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2006). COUNT II 15. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 16. That pursuant to law, staff who provide direct care to residents, who have not taken the core training program, shall receive a minimum of 1 hour in-service training within 30 days of employment that covers resident rights in an assisted living facility, and recognizing and reporting resident abuse, neglect and exploitation. R. 58A-5.0191(2)(c), Florida Administrative Code. Except as otherwise noted, certificates of any training required by this rule shall be documented in the facility’s personnel files which documentation shall include this subject matter of the training program, the trainee’s name, the date of attendance, the training provider’s name, signature and credentials, professional license number if applicable, and the number of hours of training. R. 58A-5.0191(11)(a), Florida Administrative Code. 17. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 18. That based upon the review of records, the Respondent failed to ensure that the personnel files of one (1) of five (5) sampled employees contain documentation which reflected that the employee had received a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects: 1. Resident rights in an assisted living facility. 2. Recognizing and reporting resident abuse, neglect, and exploitation. 19. That the Petitioner’s representative reviewed the Respondent’s personnel records on September 12, 2006 and noted the following regarding employee number two (2): a. That the employee had been in the Respondent’s employ for a period in excess of thirty (30) days; b. That the file did not contain any documentation reflecting that the employee had received a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects: 1. Resident rights in an assisted living facility. 2. Recognizing and reporting resident abuse, neglect, and exploitation. 20. That the failure to train and document such training as required by law in a timely manner is in violation of law. 21. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 22. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 23. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 24. That based upon the review of records, the Respondent failed to ensure that the personnel files of one (1) of five (5) sampled records contained documentation that the employee had received a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects: 1. Resident rights in an assisted living facility. 2. Recognizing and reporting resident abuse, neglect, and exploitation. 25. That the Petitioner’s representative reviewed the Respondent’s personnel records on October 30, 2006 and noted the following regarding employee number two (2): a. That the employee had been in the Respondent’s employ for a period in excess of thirty (30) days; b. That the file did not contain any documentation reflecting that the employee had received a minimum of 1 hour in-service training withir. 30 days of employment that covers the following subjects: 1. Resident rights in an assisted living facility. 2. Recognizing and reporting resident abuse, neglect, and exploitation. 26. That the failure to train and document such training as required by law in a timely manner is in violation of law. 27. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 28. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 29. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT Il 30. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 31. That pursuant to Florida law, the facility shall maintain a daily observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. The MOR must include, inter alia, 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 maintained by an assisted living facility must be immediately updated each time the medication is offered or administered. Rule 58A-5.0185(5)(b), Florida Administrative Code. 32. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 33. That based upon the review of records and interviews, the Respondent facility failed to maintain an updated medication observation record (hereinafter “MOR”) for two (2) of four (4) residents review placing residents at risk to receive the wrong dosages and in violation of the requirements of law. 34. That the Petitioner’s representative reviewed the Respondent’s records and medications regarding residents numbered two (2) and three (3) and interviewed the Respondent’s staff member on September 12, 2006 and noted as follows: a. Resident number two (2): i. iii. iv. The resident’s MOR was annotated as follows: Prilosec 40 milligrams (mg), take one capsule by mouth once daily; The prescription was labeled: Prilosec OTC 20 mg., take one daily; The Respondent’s licensed practical nurse indicated that the resident had been administered one tablet as reflected on the MOR; The dosage on the MOR was inaccurate. b. Resident number three (3): i. ii. til. The resident's MOR was annotated as follows: Coumadin 3 mg Monday, Wednesday and Friday only and Coumadin 3 mg 1/2 tab (15 mg) on Tuesday, Thursday, Saturday and Sunday; The label on the prescription bottle read: Coumadin 4.5 mg. on Monday, Wednesday, Friday and Sunday and expired on March 27, 2006; The MOR reflected a prescription in error. 35. A threat to the health and safety of a patient is inherent in not administering his or her medication as prescribed. The conditions or symptoms for which the inedication was prescribed remain unaddressed and could worsen. In addition, health care providers, including primary care physicians, consulting physicians and even emergency medical services personnel, oftentimes rely upon facility medication records in making decisions about a patient’s care and treatment. They may assume that physician orders have been followed. Patient medical records may thus reflect the administration of prescribed medication. The maintenance of an incorrect MOR is in violation of law. 36. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 37. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 38. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 39. That based upon interview and the review of records. The Respondent failed to maintain an accurate MOR for one (1) of five (5) sampled residents, the same being in violation of law. 40. That the Petitioner’s representative reviewed the Respondent’s records related to resident number two (2) on October 30, 2006 and noted the following: a. The resident's October MOR revealed conflicting orders for Warfarin (Coumadin); b. The MOR contained a notation for the resident to receive Warfarin 3mg on Tuesday, Thursday, Saturday, and Sunday; c. The MOR was noted as having been given on these days during October; d. Written above the initials was an undated note reading "Hold" crossed out, and “continue” written next to it; e. A order was also noted for 1/2 tablet of Warfarin 3mg on Sunday, which was not marked as given. 41. That the Petitioner’s representative interviewed the Respondent’s nurse on duty on October 30, 2006 who indicated that the resident’s Warfarin 1/2 tablet was a one-time-only order from the previous week, but had not been discontinued, updated, or clarified on the MOR. 42. A threat to the health and safety of a patient is inherent in not administering his or her medication as prescribed. The conditions or symptoms for which the medication was prescribed remain unaddressed and could worsen. In addition, health care providers, including primary care physicians, consulting physicians and even emergency medical services personnel, oftentimes rely upon facility medication records in making decisions about a patient’s care and treatment. They may assume that physician orders have been followed. Patient medical records may thus reflect the administration of prescribed medication. The maintenance of an incorrect MOR is in violation of law. 43. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 44. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 45. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). 10 COUNT IV 46. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 47. That pursuant to Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility including, but not limited to, daily observation of the resident and awareness of the general health, safety, and physical and emotional well-being of the resident, the maintenance of a written record, updated as needed, of any significant changes in the resident’s normal appearance or state of health and any illnesses which resulted in medical attention, and the maintenance of nursing progress notes. Florida Administrative Code R. 58A-5.0182. 48. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility, 49. That based upon the review of records and interview, the Respondent failed to provide care and services to meet the needs of the residents for the week of September 4 through 10, 2006 on the 11:00 PM to 7:00 AM shift due a lack of staff to provide supervision of residents. 50. That the Respondent’s facility is large and divided into five (5) separate wings, one of which is a secured unit. Sl. That the facility’s census for the week above referenced was seventy-two (72) with twenty (20) residents on the Main wing, nine (9) residents on the East wing, sixteen (16) residents on the secured North wing, ten (10) residents on the Northeast wing, and eleven (11) residents on the Northwest wing. 52. That the Respondent’s staffing schedules reflect the following staffing schedules for the above referenced week on the 11:00 PM to 7:00 AM shift: a. Monday September 4, 2006 — Three (3) employees to serve and monitor five (5) wings, one employee assigned for the Main and East wing, one employee assigned for the North wing, and one employee assigned for the Northwest and Northeast wings; b. Tuesday September 5, 2006 — Three (3) employees to serve and monitor five (5) wings, one employee assigned for the Main and East wing, one employee assigned for the North wing, and one employee assigned for the Northwest and Northeast wings; c. Wednesday September 6, 2006 — One (1) employee to serve and monitor all five (5) wings; d. Thursday September 7, 2006 — Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings; e. Friday September 8, 2006 — Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings. 53. - That the Petitioner’s representative interviewed the Respondent’s administrator on September 12, 200 who indicated as follows: a. That the facility usually has one (1) employee covering the Main and East wing, one (1) employee covering the Northwest and Northeast wing and two (2) employees covering the North wing; b. That the facility was not short that week because she had covered anyone's shift who did not show up. 12 54. That the Respondent’s administrator was not shown on the facility’s schedule. 55. That the Respondent planned for staffing patterns which would provide for four (40 personnel to cover the physical expanse of the facility’s care areas on the night shift. 56. That for a sample period of five (5) days the Respondent failed to provide enough appropriate staff to adequately care for and monitor the facility’s census, on each of said dates not even meeting the Respondent’s anticipated staffing pattern needs. 57. That the failure to provide sufficient qualified staff for the care and services of residents and their monitoring is in violation of law. 58. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 59. | The Agency provided Respondent with a mandatory correction date of October 12, 2006. 60. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 61. That based upon the review of records and interview, the Respondent failed to provide care and services to meet the needs of the residents for the week of October 23 through 29, 2006 on the 11:00 PM to 7:00 AM shift due a lack of staff to provide supervision of residents. 62. That the Respondent’s facility is large and divided into five (5) separate wings, one of which is a secured unit. 63. That the facility’s census for the week above referenced was sixty-two (62) with eighteen (18) residents on the Main wing, eight (8) residents on the East wing, twelve (12) residents on the secured North wing, twelve (12) residents on the Northeast wing, aiid twelve (12) residents on the Northwest wing. 64. That the Respondent’s staffing schedules reflect the following staffing schedules for the above referenced week on the 11:00 PM to 7:00 AM shift: a. Wednesday October 25, 2006 — Three (3) employees to serve and monitor all five (5) wings; b. Thursday October 26, 2006 — Three (3) employees to serve and monitor all five (5) wings; c. Friday October 27, 2006 — Three (3) employees to serve and monitor all five (5) wings; d. Saturday October 28, 2006 — Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings; e. Sunday October 29, 2006 — Two (2) employees to serve and monitor five (5) wings, one employee assigned for the Main, East and North wings and one employee assigned for the Northwest and Northeast wings. 65. That the Respondent planned for staffing patterns which would provide for four (40 personnel to cover the physical expanse of the facility’s care areas on the night shift. 66. That for a sample period of five (5) days the Respondent failed to provide enough appropriate staff to adequately care for and monitor the facility’s census, on each of said dates not even meeting the Respondent’s anticipated staffing pattern needs. 67. That the failure to provide sufficient qualified staff for the care and services of residents and their monitoring is in violation of law. 68. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 69. That the Agency provided Respondent with a mandatory correction date of November 1, 2006. 70. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT V 71. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 72. That pursuant to Florida law, no resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of the facility. Every resident of a facility shall . have a right to, inter alia, live in a safe and decent living environment, free from abuse and neglect, and be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. §429.28(1), Fla. Stat. (2006). 73. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 74. That based upon observation, the Respondent failed to comply with the Kesident Bill of Rights in regards to living in a safe and decent living environment, the same being in violation of 15 law. 75. That the Petitioner’s representative made visual observations of the facility and its environs on September 12, 2006 and noted that in room number twelve (12), there were multiple bottles of unsecured oxygen bottles behind the room door, under the bed and in the closet. 76. That oxygen bottles which are not properly secured present a safety hazard to the facility and its residents due to, inter alia, the high flammability dangers related thereto. 77. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 78. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 79. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 80. That based upon observation, the Respondent failed to comply with the Resident Bill of Rights in regards to living in a safe and decent living environment and to live free from abuse and neglect with consideration and respect and due recognition of personal dignity, the same being in violation of law. 81. That the Petitioner’s representative toured the Respondent facility and its environs an October 30, 2006 and noted the following: a. That in room number twelve (12), eight (8) large oxygen bottles were found unsecured under the resident's bed, six (6) small bottles were found unsecured next to the resident's chest of drawers, two (2) smail bottles were found lying on the floor of the bedroom, and eight (8) small oxygen bottles were found unsecured in the closet; b. That in room number five (5), two large oxygen bottles were found unsecured in the resident's closet; c. That during lunch in the forward dining room of the dementia unit, an aide was observed feeding resident number four (4); d. That while doing so, another demented resident reached for cake, attempting to obtain it; e. That rather than ordering more food for the other interloping resident, the aide feeding resident number four (4) made batting motions with her hand at the randomly observed resident reaching for the cake; f. That the resident's facial expression changed, his/her eyes widening, and s/he recoiled and withdrew his/her hands; g. That the other resident sat and stared as resident number four (4) was fed the cake, keeping his/her hands close to his/her body for some time afterwards; 82. That oxygen bottles which are not properly secured present a safety hazard to the facility and its residents due to, inter alia, the high flammability dangers related thereto. 83. That the slapping at the hands of a resident is not treating the resident with respect for the resident’s dignity. 84. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 85. That the Agency provided Respondent with a mandatory correction date of November 1, 2006. 86. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT VI 87. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 88. Pursuant to Florida law, menus to be served shall be dated and planned at least one week in advance for both regular and therapeutic diets. Residents shall be encouraged to participate in menu planning. Planned menus shall be conspicuously posted or easily available to residents. Regular and therapeutic menus as served, with substitutions noted before or when the meal is served, shall be kept on file in the facility for 6 months. R. 58A-5.020(2)(d), Florida Administrative Code. 89. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 90. That based upon observation and interview, the Respondent failed to conspicuously post or provide menus easily to residents as required by law in violation of law. 91. That the Petitioner’s representative toured the Respondent facility on September 12, 2006 and could locate no posted menus for resident awareness of meals. 92. That the Petitioner’s representative interviewed Respondent’s staff person on September 12, 2006 who indicated that she had just started so she was not aware of the menus needing to be posted and dated. 18 93. That the failure to post menus or otherwise make the same easily accessible is in violation of law. 94. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 95. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 96. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 97. That based upon observation and interview, the Respondent failed to maintain dated menus as required by law. 98. That the Petitioner’s representative toured the Respondent’s facility on October 30, 2006 and noted that the Respondent’s menus provided did not contain dates for the menu’s use. 99. That the Petitioner’s representative interviewed the Respondent’s dietary manager on October 30, 2006 who indicated that she does not date the menus she just goes by the cycle weeks and was unaware of the requirement to maintain dated menus. | 100. That the failure to maintain dated menus is in violation of law. 10). That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 102. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 103. That the same constitutes grounds for an uncorrected Class II] deficiency as defined by law. 19 WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT VII 104. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 105. That pursuant to Florida law, 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. Rule 58A-5.0023(1)(b), Florida Administrative Code. 106. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 107. That based upon observation, the Respondent failed to ensure the furnishings were maintained in clean and good condition, the same being contrary to law. 108. That the Petitioner’s representative toured the Respondent facility on September 12, 2006 and noted toilet seats in room thirteen (13), nineteen (19), and seventeen (17), were broken, filthy, and in need of repair. 109. That the failure to maintain furnishings in clean and good condition is in violation of law. 110. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 111. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 20 112. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 113. That based upon observation, the Respondent failed to ensure the furnishings were maintained in clean and good condition, the same being contrary to law. 114. That the Petitioner’s representative toured the Respondent facility on October 30, 2006 and noted the toilet seat lid in room thirteen (13) to be propped against the wall on the floor of the bathroom, the elevated toilet seat in room number seventeen (17) had a bar in the middle where a resident would sit with the regular toilet seat underneath the elevated seat and soiled and loose. 115. That the failure to maintain furnishings in clean and good condition is in violation of law. 116. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 117. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 118. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT VII 119. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fuliy set forth herein. 21 120. That pursuant to Florida law, personnel records for each staff member shall contain verification of freedom from communicable disease including tuberculosis. R. 58A-5.024(2)(a), Florida Administrative Code. §429.275(2), Florida Statutes (2006). 121. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 122. That based upon the review of records and interview, the Respondent failed to ensure that personnel records for one (1) of five (5) employees contained a verification of freedom from communicable disease including tuberculosis, this failure being in violation of law. 123. That the Petitioner’s representative reviewed the Respondent’s personnel file of employee number one (1) on September 12, 2006 and noted that it did not contain verification of the employee’s freedom from communicable disease including tuberculosis. 124. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 125. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 126. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 127. That based upon the review of records, the Respondent failed to ensure that personnel records for one (1) of five (5) employees contained a verification of freedom from communicable disease including tuberculosis, this failure being in violation of law. 128. That the Petitioner’s representative reviewed the personnel records of the Respondent on October 30, 2006 and noted that the personnel record of empioyee number one (1) did not 22 contain a verification of freedom from communicable disease including tuberculosis as is required by law. 129. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 130. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 131. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT IX 132. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 133. That pursuant to Florida law, newly hired staff shall have 30 days to submit a statement from a health care provider ... that the person does not have signs or symptoms of a communicable disease including tuberculosis. Freedom from tuberculosis must be documented onan annual basis. R. 58A-5.019(2)(a), Florida Administrative Code. The personnel records of each staff member shall include verification that the staff member is free of communicable diseases including tuberculosis. R. 58A-5.024(2)(a), Florida Administrative Code. 134. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 23 135. That based upon the review of records, the Respondent failed to maintain annual documentation of freedom from tuberculosis on an annual basis for two (2) of five (5) personnel records reviewed, the same being in violation of law. 136. That the Petitioner’s representative reviewed the personnel files of the Respondent on September 12, 2006 and noted that the files of employees numbered one (1) and two (2), who had been employed for more than one year did not contain annual verification of freedom from tuberculosis as required by law. . 137. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 138. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 139. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 140. That based upon the review of records, the Respondent failed to maintain annual documentation of freedom from tuberculosis on an annual basis for one (1) of five (5) personnel records reviewed, the same being in violation of law. 141. That the Petitioner’s representative reviewed the personnel files of the Respondent on October 30, 2006 and noted that the files of employees numbered one (1), who had been . employed for more than one year did not contain annual verification of freedom from tuberculosis as required by law. 142. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 24 143. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 144. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT X 145. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 146. That pursuant to Florida law, the administrator or owner of a facility must maintain a personnel record for each staff member. Section 429.275 Florida Statutes (2006). Said records must be maintained by the facility accessible to department and agency staff, and must contain, as applicable, inter alia, documentation of compliance with all staff training required by Rule 58A-5.0191, F.A.C. Florida Administrative Code R. 58A-5.024(2)(a)(1), Florida Administrative Code R. 58A-5.0191(11). All facility employees must complete biennially, a continuing education course on HIV and AIDS. New facility staff must obtair. an initial training on AIDS/HIV within thirty days of employment, unless the new staff person previously completed the initial training and has maintained the biennial continuing education training. Florida Administrative Code R. 58A-5.0191 (3). 147. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 25 148. That based upon the review of records, the Respondent failed to ensure that employee personnel files contained verification that two (2) of five (5) sampled employees had completed, within thirty (30) days of employment, initial training on HIV/AIDS within 30 days of employment had been obtained. 149, That the Petitioner’s representative reviewed the Respondent’s personnel records on September 12, 2006 and noted that the files of employees numbered one (1) and two (2), both of who were employed with the Respondent in excess of thirty days, did not contain verification that the employees had completed initial training on HIV/AIDS within 30 days of employment, the same being in violation of law. 150. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 151. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 152. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 153. That based upon the review of records, the Respondent failed to ensure that employee personnel files contained verification that two (2) of five (5) sampled employees had completed, within thirty (30) days of employment, initial training on HIV/AIDS within 30 days of employment had been obtained. 154. That the Petitioner’s representative reviewed the Respondent’s personnel records on October 30, 2006 and noted that the files of employees numbered one (1) and two (2), both of who were employed with the Respondent in excess of thirty days, did not contain verification 26 that the employees had completed initial training on HIV/AIDS within 30 days of employment, the same being in violation of law. 155. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 156. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 157. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT XI 158. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 159. That pursuant to Florida law, staff involved with the management of medication and assisting with the self-administration of medications... must complete a minimum of 4 additional hours of training. §429.52(5), Florida Statutes (2006). All unlicensed persons who will be providing assistance with self-administered medications as described in Rule 58A-5.0185, F.A.C., must receive a minimum of 4 hours of training prior to assuming this responsibility. Florida Administrative Code R. 58A-5.0191(5). “Unlicensed person” means an individual not currentiy licensed to practice nursing or medicine... who has received training with respect to assisting with the self-administration of medication in an assisted living facility... §429.526, 27 Florida Statutes (2006). Personnel records for each staff member shall contain, at a minimum...Documentation of compliance with all staff training required by Rule 58A-5.0191, Florida Administrative Code R. 58A-5.024(2)(a)(1), Florida Administrative Code Rule 58A- 5.0191(11)(a). 160. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 161. That based upon the review of records, the Respondent failed to ensure that one (1) of five (5) sampled personnel records contained verification that the employee had undergone required medication training prior to assuming such duties as required by law. 162. That the Petitioner’s representative reviewed the personnel file of employee number four (4) on September 12, 2006 and noted that the employee provides assistance with self- administration of medications and that the file contained no verification that the employee had completed a minimum of four (4) hours of training in providing assistance with self-administered medications prior to assuming such duties. 163. That the failure to obtain said training and or maintain verification thereof is in violation of law. 164. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 165. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 166. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 28 167. That based upon the review of records, the Respondent failed to ensure that one (1) of five (S) sampled personnel records contained verification that the employee had undergone required medication training prior to assuming such duties as required by law. 168. That the Petitioner’s representative reviewed the personnel file of employee number four (4) on September 12, 2006 and noted that the employee provides assistance with self- administration of medications and that the file contained no verification that the employee had completed a minimum of four (4) hours of training in providing assistance with self-administered medications prior to assuming such duties. 169. That the failure to obtain said training and or maintain verification thereof is in violation of law. 170. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 171. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 172. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT XII 173. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29 174. | That pursuant to the Florida Administrative Code, staff members who prepare or serve food must, within thirty days of employment, receive a minimum of one hour training in safe food practices. Florida Administrative Code R. 58A-5.0191(2)(e). Documentation of said employee education must be maintained in the employee’s personnel file, Florida Statutes 400.4275(2)(2003), Florida Administrative Code R. 58A-5.0191(10)(e), Florida Administrative Code R. 58A-5.024 (2)(a). 175. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 176. That based upon the review of records, the Respondent failed to ensure that three 93) of five (5) personnel files reflect that the employees had received a minimum of 1-hour in-service training within 30 days of employment in safe food handling practices. 177. That the Petitioner’s representative reviewed Respondent’s personnel files on September 12, 2006 and noted as follows: a. That employees numbered three (3), four (4), and five (5) serve food to residents; _ b. That the employees had all been employed in excess of thirty (30) days; c. That the personnel files of these employees did not contain verification that the employees had completed a minimum of 1-hour in-service training in safe food handling practices. 178. That the failure to obtain and or maintain verification of the completion of required training in safe food handling practices is in violation of law. 179. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentiaily threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 30 180. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 181. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 182. That based upon the review of records, the Respondent failed to ensure that three 93) of five (5) personnel files reflect that the employees had received a minimum of 1-hour in-service training within 30 days of employment in safe food handling practices. 183. That the Petitioner’s representative reviewed Respondent’s personnel files on October 30, 2006 and noted as follows: a. That employees numbered three (3), four (4), and five (5) serve food to residents; b. That the employees had all been employed in excess of thirty (30) days; c. That the personnel files of these employees did not contain verification that the employees had completed a minimum of 1-hour in-service training in safe food handling practices. 184. That the failure to obtain and or maintain verification of the completion of required training in safe food handling practices is in violation of law. 185. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 186. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 187. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. 31 WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT XII 188. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 189. That pursuant to Section 429.174(2), Florida Statutes (2006), the owner or administrator of an assisted living facility must conduct level 1 background screening, as set forth in Chapter 435, Florida Statutes (2005), on all employees hired on or after October 1, 1998, who perform personal services as defined in Section 429.02(17), Florida Statutes (2006). 190. That pursuant to Florida law, the term “personal services” is defined as “direct physical assistance with or supervision of the activities of daily living and the self-administration of medication and other similar services which the [D]epartment [of Elder Affairs] may define by rule.” Section 429.02(17), Florida Statutes (2006). 191. That pursuant to Florida law, all assisted living facility staff hired on or after October 1, 1998, to provide personal services to residents must be screened in accordance with Section . 429.174, Florida Statutes (2006), and meet the screening standards of Section 435.03, Florida Statutes (2006). Rule 58A-5.019(3)(a), Florida Administrative Code. 192. That pursuant to Rule 58A-5.019(3)(a)(1), Florida Administrative Code (2006), within ten (10) days of an individual’s employment, the assisted living facility shall submit, inter alia, a completed Criminal History Check (AHCA Form 3110-0002) to the Agency’s central office. 193. That pursuant to Section 429.275(2), Florida Statutes (2006), the administrator or owne: of an assisted living facility shall maintain personnel records for each staff member which 32 contain, at a minimum, documentation of background screening. 194. That pursuant to Florida law, personnel records for each assisted living facility staff member shall contain, inter alia, documentation of compliance with level 1 background screening for all staff subject to screening requirements as required under Rule 58A-5.019, Florida Administrative Code (2006). Rule 58A-5.024(2)(a)(3), Florida Administrative Code. 195. That on September 12, 2006, the Agency conducted a Change of Ownership (CHOW) Survey of the Respondent facility. 196. That based upon the review of records, the Respondent failed to ensure that all employees who provide personal services obtain a level 1 criminal background screening, the same maintained in the employee’s personnel file, as required by law: 197. That the Petitioner’s representative reviewed the Respondent’s personnel files on September 12, 2996 and noted as following: a. That employees numbered one (1), two (2), and three (3) all provide personal services to residents; b. That none of the files of these employees contained verification that the employee had undergone a level 1 criminal background screening. 198. That the failure to ensure staff of a facility are free from criminal involvement barring their employment in an assisted living facility is in violation of law. 199. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 200. The Agency provided Respondent with a mandatory correction date of October 12, 2006. 33 201. That on October 30, 2006, the Agency conducted a revisit to the Change of Ownership (CHOW) Survey of the Respondent facility. 202. That based upon the review of records, the Respondent failed to ensure that all employees who provide personal services obtain a level 1 criminal background screening, the same maintained in the employee’s personnel file, as required by law. 203. That the Petitioner’s representative reviewed the Respondent’s personnel files on October 30, 2996 and noted as following: a. That employees numbered one (1),and two (2), provide personal services to residents; b. That none of the files of these employees contained verification that the employee had undergone a level 1 criminal background screening. 204. That the failure to ensure staff of a facility are free from criminal involvement barring their employment in an assisted living facility is in violation of law. 205. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 206. That the Agency provided Respondent with a mandatory correction date of November 30, 2006. 207. That the same constitutes grounds for an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondexii, an assisted living facility in the State of Florida, pursuant io Section 429.19(2)(c), Florida Statutes (2006). 34 Respectfully submitted this 26 day of April, 2007. Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7005 1160 0002 2254 8900 on April 2 G , 2007 to Katrin Feick, Administrator, Palmetto Guest Home, Inc., 820 — 5" Street West, Palmetto, FL 34221 and Jacqueline Dorelien, Reg. Agent, Palmetto Guest Home, Inc., 820 — 5" Street West, Palmetto, FL 34221. 35 Copies furnished to: [ Katrin Feick Administrator Paimetto Guest Home, Inc. 820-5" Street West Palmetto, FL 34221 -S. Certified Mail) Kathleen Varga Facility Evaluator Supervisor 525 Mirror Lake Dr., 4" Fl. St. Petersburg, Florida 33701 (nteroffice) Jacqueline Dorelien Registered Agent Palmetto Guest Home, Inc. 820 ~ 5" Street West Palmetto, FL 34221 -S. Mail Thomas J. Walsh, I Senior Attorney Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 36 ServeStar - Invoice ; wm, Page lof! VERIFIED RETURN OF SERVICE fussy , a5. 4 OF State of County of WT pout Case Number: 2007005669 Court Date: Style of Case: STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMIN!STRATION vs. M. VILLARD, INC. DBA PALMETTO GUEST HOME. INC. PATRICIA CAUFMAN AGENCY FOR HEALTH CARE ADMINISTRATION 525 MIRROR LAKE DR. NORTH #419 ST. PETERSBURG, FL33701-3219 Received by BOLTER & CARR INVESTIGATIONS, INC. on-the Wednesday, May 23, 2007 at 1:52:30 PM to be served on JACQUELINE DORELIEN OR KATRIN FEICK, ADMINISTRATOR FOR PALMETTO GUEST HOME, !NC., 820 - 5TH STW. PALMETTO, FL 24221. ; 1, Eimer 8. Frost, dc hereby affirm that on the Wednesday, May 23, 2007 at 3:49 PM, |: Served the within named corporation by delivering a true copy of the 2 ADMINISTRATIVE COMPLAINTS, ELECTION OF RIGHTS with the date and hour of service endersed thereon by me to JACQUELINE DORELIEN as ADMINISTRATOR of the within named corperaticn, in compliance with State Statutes. Comments pertaining to this service: | certify that! am over the age of 18, and have no interest in the above action. Under penalties of perjury, | declare that | have read the foregoing (RETURN OF SERVICE) and that the facts stated in iC are true, per Fla statute 92.525(2) Elmer B. Frost 94-133 BOLTER & CARR INVESTIGATIONS, INC. P.O. BOX 8966. TAMPA, FL 33674-8965 (813) 251-6033 Job Number: 2007005414 Awww bolterandcarr.convprint affidavitasp?UID=404 [3898¢@[D=406562JID=200... ze SERLPSTeLs eo RIEOg ate INVESTIGATIONS iy “, cunt |oaminar joomestic |erocess Oyu oe “Apiary Ve FAX COVER SHEET aS DATE: S |a3 O71 ro: Voleve 2 Vous rax#: (2 1-SS3-(U4UO From: CCL 4 # OF PAGES INCLUDING COVER: a PO. Box 8965, Tampa, FL 33674-8965 AI 251-6023 [vow Free (S00) 251-6023 ex (972) 252-7882! wwwbolrerandcarr.com Vd eBezrszele ueogieqog —dazipo 10 &2 AON

Docket for Case No: 07-002873