val STATE OF FLORIDA EO TY pm AGENCY FOR HEALTH CARE ADMINISTRATION 07 Th Ee PY , hoy. TATE OF FLORIDA, Y~9 py bs AGENCY FOR HEALTH CARE ae apel¥isinn . 26 ADMINISTRATION, SID SDhinyoetl OF ? : ie rw) RAT . ARH GATE Petitioner, ; vs. Case No. 2007005292 WESTWOOD MANOR, 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 WESTWOOD MANOR, (hereinafter Respondent) pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: o NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of TWO THOUSAND ’ SEVEN HUNDRED FIFTY DOLLARS ($2,750.00), based upon five uncorrected Class III deficiencies against the Respondent, pursuant to Sections 429. 19(2)(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 Rule 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living Page 1 of 20 _ 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 (2006), and Chapter 58A-5 Florida Administrative Code (2006), respectively. 4. Respondent operates a 30-bed assisted living facility located at 2339 _ Hoople Street, Fort Myers, Florida 33901. Respondent is and was at all times material hereto a licensed facility, having been issued license number 8914. COUNT I The Respondent’s Administrator Failed To Provide Adequate Management And Maintenance Of The Facility In Violation Of Rule 58A-5.019(1), Florida Administrative Code (2006) 5. The Agency re-alleges and incorporates paragraphs (1) through (4) as if fully set forth herein, 6. Pursuant to Florida law, every facility shall be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents as required by Part I of Chapter 429, Florida Statutes (2006) and Rule 58A-5.019(1), Florida Administrative Code (2006). , | 7. On or about December 28, 2006, Agency surveyors conducted. a Follow-Up Survey to a Complaint Survey of the Respondent’s facility that resulted in a Class III deficiency. 8. Based upon failure to correct deficiencies from Complaint Investigations CCR# 2006- 002466 initially investigated on March 22, 2006, and not all citations substantially corrected on May 11, 2006, June 21, 2006, August 31, 2006, and November 16, 2006. Further based upon failure to correct deficiencies from Complaint Investigation, CCR# 2006-005717, initially investigated on August 31, 2006 and not all citations substantially corrected on November 16, 2006. Further based upon deficiencies from the Biennial survey of November 16, 2006 the Administrator failed to provide adequate management and maintenance of the facility. Page 2 of 20 9. Complaint Investigations, CCR# 2006-002466 and CCR# 2006-001497, were completed. on March 22, 2006. Both complaints were confirmed and the facility was issued five (5) citations as a result of these complaints. Refer to State Form dated March 22, 2006 for additional information regarding these citations. Citations A304 and A1005 remain uncorrected after five revisits. 10, On May 11, 2006, a Follow-Up Survey was completed to the original two complaints which resulted in deficiencies. Three (3) citations were uncorrected, and three (3) new citations were cited. Refer to the State Form dated May 11, 2006 for additional information regarding these citations. 11. On June 21, 2006, a second Follow-Up Survey was completed to- the original two (2) complaint surveys. Three citations were uncorrected and two (2) new citations were cited. Refer to the State Form 3020-0001 dated June 21, 2006 for additional information regarding these citations. 12. On August 31, 2006, a third follow up survey was completed to the original two complaint surveys. Three citations were uncorrected and recited. Refer to State Form dated August 31, 2006 for citations related to CCR# 2006-002466 and CCR# 2006-001497 for additional information regarding these uncorrected citations. 13. Anew complaint investigation, CCR# 2006-005717, was conducted on August 31, 2006. The complaint was confirmed and nineteen (19) new citations were cited. Refer to State Form dated August 31, 2006 for additional information regarding citations from this complaint survey. 14. On November 16, 2006, a fourth follow up to the original two complaints was conducted. There were two (2) uncorrected deficiencies which were recited, Refer to State Form dated November 16, 2006 for additional information regarding CCR# 2006-002466 and CCR# 2006-001497 and these uncorrected citations. 15. Onatevisit of November 16, 2006 there were ten (10) uncorrected citations from CCR# 2006-005717 originally cited on the August 31, 2006 which were recited on November 16, 2006. Refer Page 3 of 20 to State Form 3020-0001 dated November 16, 2006 for additional information regarding these uncorrected citations for CCR# 2006-005717. . 16. Also, there were nineteen (19) new citations cited at the Biennial survey of November 16, 2006 and one (1) repeat deficiency (originally cited on the 2nd follow up survey to CCR# 2006-002466 and CCR# 2006-001497 of June 21, 2006 (A1004)), The Biennial survey included a new complaint, CCR# 2006-009886, which was confirmed with two citations (A718 and A1004). 17. It is noted the Administrator/Owner failed to obtain the required twelve (12) hours of continuing education required for Administrators, This failure was cited at A505 on the Biennial Survey. . 18. The Administrator failed to assure that citations related to Self Administration of Medications were corrected in a timely fashion. 19. The Administrator failed to obtain a minimum of two (2) hours continuing education training on providing assistance with self administered medications and safe medication practices in an Assisted Living Facility. . 20, The Administrator failed to obtain a Consulting Pharmacist within ten (10) days, as required, for failing to correct three (3) Class IIT Medication citations from the complaint investigation CCR# 2006-005717 of August 31, 2006. 21. - Such violations constitute the grounds for the imposed Class Iii deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. , 22. For this Class Il deficiency, the Agency provided the Respondent a mandated correction date of January 28, 2007. Page 4 of 20 23. On or about April 5, 2007 the Agency conducted a third follow-up survey to the Biennial licensure with limited nursing services survey completed on November 16, 2006 and revisited on December 28, 2006. . 24. . Based upon failure to correct deficiencies from Complaint Investigations CCR# 2006-002466 initially investigated on March 22, 2006, and not all citations substantially corrected on May 11, 2006, June 21, 2006, August 31, 2006, and November 16, 2006. Further based upon failure to correct deficiencies from Complaint Investigation, CCR# 2006-005717, initially investigated on August 31, 2006 and not all citations substantially corrected on November 16, 2006. Further based upon deficiencies from the Biennial survey of November 16, 2006 and follow up surveys on December 28, 2.006 and April 5, 2007, the Administrator failed to provide adequate management and maintenance of the facility. 25. Complaint Investigations, CCR# 2006-002466 and CCR# 2006-001497, were completed on March 22, 2006. Both complaints were confirmed and the facility was issued five (5) citations as a result of these complaints. Refer State Form dated March 22, 2006 for additional information regarding these citations. Citation A304 remains uncorrected after six (6) revisits. 26. On May 11, 2006, a follow up survey was completed to the original two complaints which resulted in deficiencies. Three (3) citations were uncorrected, and three (3) new citations were cited. Refer to the State Form dated May 11, 2006 for additional information regarding these citations. 27. On June 21, 2006, a second follow-up survey was completed to the original two complaint surveys. Three citations were uncorrected and two (2) new citations were cited. Refer to the State Form 3020-0001 dated June 21, 2006 for additional information regarding these citations. Page 5 of 20 28. On August 31, 2006, a third follow-up survey was completed to the original two (2) complaint surveys. Three (3) citations were uncorrected and recited. Refer to State Form dated August 31, 2006 for citations related to CCR# 2006-002466 and CCR# 2006-001497 for additional information regarding these uncorrected citations. 29. A new complaint investigation, CCR# 2006-005717, was conducted on August 31, 2006. The complaint was confirmed and nineteen (19) new citations were cited. Refer to State Form dated August 31, 2006 for additional information regarding citations from this complaint survey. . 30. On November 16, 2006, a fourth follow up to the original two complaints was . conducted, There were two (2) uncorrected deficiencies which were recited. Refer to State Form dated November 16, 2006 for additional information regarding CCR# 2006-002466 and CCR# 2006- 001497 and these uncorrected citations. 31. Also, there were nineteen (19) new citations cited at the Biennial survey of November 16, 2006 and one (1) repeat deficiency (originally cited on the 2nd follow up survey to CCR# 2006-002466 and CCR# 2006-001497 of June 21, 2006 (A1004)). The Biennial survey included a new complaint, CCR# 2006-009886, which was confirmed with two citations (A718 and A1004). 32. On April 5, 2007, a fourth follow up to the Biennial survey of November 16, 2006 was completed with seven (7) repeat deficiencies and eight (8) new deficiencies were cited. 33. Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 34. For this Class III deficiency, the Agency provided the Respondent a mandated correction date of May 5, 2007. Page 6 of 20 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 IL The Respondent Failed To Engage 5 Engage The Services Of A Consultant Pharmacist In Violation Of Rule 58A-5.033(4)(a)2, Florida Administrative Code (2006) 35. The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein. . 36. Pursuant to Florida law, if a Class J, Class II, or uncorrected Class III deficiency directly relating to facility medication practices as established in Rule 58A-5.0185, Florida Administrative Code (2006), is documented by agency personnel pursuant to an inspection of the facility, the agency shall notify the facility in writing that the facility must employ, on staff or by contract, the services of a pharmacist licensed pursuant to Section 465. 0125, Florida Statutes, or registered nurse, as determined by the agency. Rule 58A-5.033(4)(a)2, Florida Administrative Code (2006). ) . 37. . On or about December 28, 2006, Agency surveyors conducted a Follow-Up Survey to a Complaint Survey of the Respondent’s facility that resulted in a Class III deficiency. 38. . Based on record review the facility failed to engage the services of a Consultant Pharmacist within fourteen (14) working days of the jdentification of uncorrected Class I deficiencies. . 39, The facility had uncorrected Class Il medication deficiencies from Complaint Investigation, CCR# 2006-005717, completed August 30, 2006 and two (2) new Class Tl medication deficiencies cited on the Biennial survey on November 15, 2006 through November 16, 2006, and the Agency For Health Care Administration required that the facility engage the Page 7 of 20 services of a Consultant Pharmacist to ensure that staff has been trained on proper medication practices. 40. — The facility engaged Consultant Pharmacist on December 08, 2006. The contract and an in-service provided reflect that date, fifteen (15) working days after the survey of ~. November 16, 2006. | 41... For this Class TIT deficiency, the Agency provided the Respondent a mandated correction date of January 28, 2007. . 42. On or about April 5, 2007 the Agency conducted a third follow-up survey to the Biennial Licensure with limited nursing services survey completed on November 16, 2006 and revisited on December 28, 2006. 43. . Based on record review, the facility failed to engage the services of a Consultant Pharmacist within fourteen (14) working days of the identification of uncorrected Class Il ; deficiencies. . | 44, The facility had uncorrected Class II medication deficiencies from Complaint Investigation, CCR# 2006-005717, completed August 30, 2006, two (2) new Class. III medication deficiencies cited on the Biennial survey on November 15, 2006 through November 16, 2006, and repeat Class III medication citations on the follow up survey completed on December 28, 2006. The Agency for Health Care Administration required the facility engage the services of a Consultant Pharmacist to ensure that staff has been trained on proper medication practices. 45. The facility engaged a Consultant Pharmacist on February 1, 2007. The contract provided reflected that date, twenty-five (25) days after the survey of December 28, 2006. Page 8 of 20 46. Such violations constitute the grounds for the imposed Class II deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 47. Pursuant to Section 400.419(2)(c), Florida | Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 48. For this Class Ill uncorrected deficiency, the Agency provided the Respondent a mandatory correction date of May 5, 2007. 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 Jit Respondent Failed to Have A Signed And Dated Pharmacy Consultant Or Registered Nurse Consultant Recommended Corrective Action Plan No Later Than Ten (10) Working Days Subsequent To The Initial On-Site Consultant Visit in Violation of Rule 58A-5.033(4)(a)2, Florida Administrative Code (2006) 49. The Agency re-alleges and incorporates paragraphs (1). through (4) above as if fully set forth herein. 50. Pursuant to Florida law, the initial on-site consultant visit shall take place within seven (7) working days of the identification of a Class I or Class Il deficiency and within 14 working days of the identification of an uncorrected Class HI deficiency. The facility shall have available for review. by the agency a copy of the pharmacist’s or registered nurse’s license and a signed and dated recommended corrective action plan no later than 10 working days subsequent to the initial on-site consultant visit. Rule 58A-5.033(4)(a)2, Florida Administrative Code (2006). Page 9 of 20 51. Onor about December 28, 2006, Agency surveyors conducted a Follow-Up Survey to a Complaint Survey of the Respondent's facility that resulted in a Class II deficiency. 52. Based on record review and interview the facility failed to have a recommended corrective action plan within ten (10) working days subsequent to the initial on-site consultant visit. 53. The Agency required the facility engage the services of a Consultant Pharmacist to ensure that staff has been trained on proper medication practices. . 54. The facility engaged Consultant Pharmacist on December 08, 2006. The contract and an in-service provided reflect that date. 55. The contract includes monthly medication management monitoring, monthly : review of physician's orders, a four (4) hour medication course and a two (2) hour medication course. 56. Asof this survey (December 28, 2006), no action other than the initial in-service is evident. There is no action plan to review the system wide problems of medication assistance in the facility. 57. For this Class I deficiency, the Agency provided the Respondent a mandated correction date of January 28, 2007. 58. Onor about April 5, 2007 the Agency conducted a third follow-up survey to the Biennial licensure with limited nursing services survey completed on November 16, 2006 and revisited on December 28, 2006. 59. Based on record review and interview, the facility failed to have a recommended corrective action plan within ten (10) working days subsequent to the initial on-site consultant visit. Page 10 of 20 60. The Agency required the facility engage the services of a Consultant Pharmacist to ensure that staff has been trained on proper medication practices. 61. The facility engaged a Consultant Pharmacist on February 1, 2007. The facility provided documented information to reflect that date. 62, The Consultant Pharmacist provided the facility with a medication storage - inspection and medication supervision policies and procedures on February 1, 2007. As of this survey (April 5, 2007), no action plan was evident. The facility was given an opportunity to substantiate the presence of an action plan as required. There was no action plan present to review the system wide problems of medication assistance in the facility. 63. Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class IL violations. . 64. Pursuant to Section 400.419(2)(c), Florida Statutes, Class IIT violations are subj ect to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation . 65. For this Class III uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of May 5, 2007. . 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 IV Respondent Failed To Promote A Residential, Non-Medical Environment, And Provide For The Safe Care And Supérvision Of All Residents In Violation Of Rule ; 58A-5.023(1)(a), Florida Administrative Code (2006) 66. The Agency re-alleges and incorporates paragraphs (1) through (4) as if fully set forth herein. Page 11 of 20 67. Pursuant to Florida law, the Assisted Living Facility shall be located, designed, equipped, and maintained to promote a residential, non-medical environment, and provide for the safe care and supervision of all residents. Rule 58A-5.023(1)(a), Florida Administrative Code (2006). 68. . On or about December 28, 2006, Agency surveyors conducted a Follow-Up Survey to a Complaint Survey of the Respondent’s facility that resulted in a Class III deficiency. . 69. Based on observations and interviews, the facility failed to promote a safe, residential environment for the facility residents, 70. Onatour of the facility on December 28, 2006 at about 10:00 a.m. the following observations were made. 71. Apink upholstered chair and several pieces of dry wall are blocking a signed. exit corridor in the common area adjacent to the laundry room. The exit sign in the same corridor is not illuminated. | 72, ° Ahallway light located near Room four (4) is missing a light bulb and the hallway ceiling has stains on it. The exit corridor located by Room four (4) is blocked by a small step ladder and the exit sign is not illuminated. 73. The hallway by Room three (3) has a hole in the wall about 3 1/2 inches high and 9 inches wide. There are electrical wires located inside the wall opening. An interview with the Manager-on-Duty on December 28, 2007 at about 10:13 a.m. revealed that the walls are open for plumbing work and the wires may be live. 74, Room five (5) has two 4 by 8 foot sheets of dry wall leaning against the wall. A6 foot long 2 by 4 is extending about 4 feet from under the bed. A.6 foot section of base board is loose exposing a 2 % inch nail pointing into the room. Page 12 of 20 75. Room five (5) contains a twin bed and a small table. There is a closet that contains male clothing and numerous personal items are on the table. A Christmas stocking is -attached to the wall with a wrapped gift inside. ‘76. During the initial tour at approximately 10:00 a.m., it was noted there was two (2) pieces of wall board leaning against the wall in Room five (5). One of the pieces was full size approximately 8 feet by 4 feet, and the other was approximately % the size of the other. These pieces were blocking the bath room door. Staff indicated during interview at the tour time, the bathroom in this room is being reconstructed and all of the bathroom fixtures are out of the room. The wall board is in place to prevent the resident living in this room from going into the bathroom and urinating on the floor. 77, An interview with the Executive Director on December 28, 2006 at about 11:30 a.m. revealed that the resident does not currently live in the room while the renovations are being completed. The resident does keep his belongings there. The Executive Director stated that the room condition was "not acceptable." 78. The bathroom next to Room five (5) has a missing light bulb. 79, The hallway by Room five (5) has a light fixture that has one (1) of two (2) bulbs burned out. 80. . The door to Room eight (8) has no door knob. The room contains two (2) power saws, three (3) bathroom sinks, two (2) cans of PVC cement, and a one (1) gallon container that is labeled “paint thinner" and is half full. 81. A 4by 8 foot sheet of dry wall was leaning up against the hallway wall, blocking the hand rail. . 82. A fluorescent light located on the hallway outside of Room eighteen (18) is not working. Page 13 of 20 83. Aninterview with the facility Executive Director on December 28, 2006 at about 11:30 a.m. revealed that the exit corridors are blocked and will be cleared and the signs repaired. , She will have someone cover the hole in the wall in the hallway by Room three (3). She stated that the facility is currently being renovated. . 84. There has been no completion date set for the "renovations." | 85. . ‘For this Class II deficiency, the Agency provided the Respondent a mandated correction date of January 28, 2007. 86. | On or about April 5, 2007 the Agency conducted a third follow-up survey to the Biennial licensure with limited nursing services survey completed on November 16, 2006 and revisited on December 28, 2006. 2 87. Based on observation, the facility failed to promote a safe, residential environment for the facility residents. This is evidenced by the fire exit being blocked by . wallboard being stored in an exit. . . ; 88. During a tour with the Administrator on April 5, 2007 wallboard and other material was observed to be stored in fire exit area near utility room. 89, . Such violations constitute the grounds for the imposed Class ILI deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class Lor Class II violations. . . . 90, Pursuant to Section 400.419(2)(c), Florida Statutes, Class IN violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 91, For this Class III uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of May 5, 2007. Page 14 of 20 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 Respondent Failed To Maintain Doors, Plumbing, And Appliances In Good Working Order In Violation Of Rule 58A-5.023(1)(b) Florida Administrative Code (2006) 92. The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein. | 93. Pursuant to Florida law, The facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair. Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. Windows, doors, plumbing, and appliances shall be functional and in good working - order. All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. Appliances may be disabled for safety reasons provided they are functionally available when needed. . 94. Based upon observation, record review, and interview, it was determined the facility failed to maintain doors and appliances in good working order. 95. This is the fifth follow-up survey conducted on December 28, 2006. This is an uncorrected citation from the complaint survey conducted on November 15, 2006. 96. Observation of the facility on December 28, 2006 at about 10:47 am. revealed the bathroom door in Room eighteen (18) to be filled with drywall compound. The door had not been painted. 97. The plan of correction indicated that "the bathroom door in Room eighteen (18) was repaired and varnished." The completion date was indicated as "December 15, 2006." Page 15 of 20 98. An interview with the Executive Director on December 28, 2006 at about 11:30 am. revealed, "I was told it was to be repainted. It looks like it didn't get done." 99. Anobservation of the facility dryer on December 28, 2006 at about 10:03 am. revealed that the lint trap was torn along the top of the trap. It was also observed that the dryer lint trap was full of lint and appeared to be in need of cleaning. 100. For this Class III deficiency, the Agency provided the Respondent a mandated correction date of January 28, 2007. 101. Onor about April 5, 2007 the Agency conducted a third follow-up survey to the Biennial licensure with limited nursing services survey completed on November 16, 2006 and revisited on December 28, 2006. | 102. Based upon observation and tour with the Administrator, it was determined the facility failed to maintain doors, plumbing, and appliances in good working order. This is an uncorrected citation from the biennial survey conducted on November 15, 2006. 103. Room one (1): Window screen torn, bookcase away from wall at right top corner, and needs caulking. 104. Bathroom near Room two (2): Broken shower head, rust in tub drain, and chipped soap dish. 105. Utility area: washing machine (spare) not clean, excessive lint in dryer lint filter, cracked wall, sliding glass door unable to close fully. 106. Room eleven (11): Tub spigot and drain dirty, towel rack broken. 107. Room seventeen (17): Broken window screen, ‘unfinished door repair (spackled and not finished) and no stopper in bathroom sink drain. 108. Bathroom by Room one (1): Cracked caulking around bath tub. Dusty towel rack and no stopper for sink. Page 16 of 20 109. Room three (3): The light bulb is burned out. 410. Hallway air conditioner dripping water on floor by Room four (4). Per interview with a resident this has been occurring for several days. 111. Room nine (9)- Empty. Bathroom ceiling tile is stained. The lint trap in the dryer has not been cleaned and the filter still has a holé, which was cited on December 28,-2006. 112. Room eighteen (18) - no stopper for sink in bathroom. The wall paper was spackled to hold towel rack. When pointed out to Administrator he stated, “I would have to paper the whole room to make it look tight.” 113. Television room - Return air vent drooping down from ceiling, 114, Hall vent in the hallway by Room twelve (12) is dirty. 115. Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class u violations. 116. Pursuant to Section 400.419(2)(c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 117. For this Class III uncorrected deficiency, the Agency provided the Respondent _ with a mandatory correction date of May 5, 2007. . WHEREFORE, the Agency intends to impose an. administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). Page 17 of 20 CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of TWO. THOUSAND SEVEN HUNDRED FIFTY DOLLARS ($2,750.00). 3. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this By of October, 2007. Qin 9 2 ee (An - 4 Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration ° Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 . NOTICE THE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. IF THE RESPONDENT WANTS TG HIRE AN ATTORNEY, JT/HE/SHE HAS THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN , THE ATTACHED ELECTION OF RIGHTS FORM. : THE RESPONDENT IS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. THE ELECTION OF RIGHTS FORM SHALL BE MADE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION AND DELIVERED TO: AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BUILDING 3, MAIL STOP 3, TALLAHASSEE, FL 32308; TELEPHONE (850) 922-5873. Page 18 of 20 CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No: 7006 2150 0004 5871 0811 on October _& __, 2007 to: Peter Kramer, Administrator, Westwood Manor, 2339 Hoople Street, Fort Myers, Florida 33901. Nn. Andrea M. Lang, Senior Attorney Florida Bar No.0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Office: (239) 338-3203 Fax: (239) 338-2699 Page 19 of 20 Copies furnished to: John F. Gilroy Il, P. A. Andrea M, Lang, Senior Attorney Fort Myers, Florida 33901 | (U.S, Certified Mail) Counsel for Respondent Agency for Health Care Administration Westwood Manor Office of the General Counsel 1435 East Piedmont Drive, Suite 215 2295 Victoria Avenue, Room 346C Tallahassee, Florida 32308 Fort Myers, Florida 33901 (U.S. Mail) (Interoffice Mail) Peter Kramer, Administrator Kriste J. Mennella Westwood Manor. Field Office Manager 2339 Hoople Street Agency for Health Care Administration | 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) Page 20 of 20 ~ od dy, 4 4 Z| b oO, . 4; | Tift "€? SENDER: COMPLETE THIS SECTION *, im Complete ttems 1, 2, and 3, Also complete | item 4 if Restricted Delivery Is desired. : x ‘ DAgent ; ™@ Print your'name and address on the reverse C1 \Adcressee so that we can return the card to you.’, . B.. Received by ( Printed Ni O. Date of Deliv { if Attach this card to the back of the malipiece, : acelved by (Frin ame) a ° or eney or on the front if space permits... id Articla Addressed to: | t : Pe ker Kramer, Adonss fos be i Westword jrener ete t ] ; D.- Is delivery address different from Item 1? C1 Yes (EYES, enter delivery address below: . CO No 2339 tfeaple Sheet ; Fart Myers, Florida 3390; : 2, Articla Number :; | (Transfer from’service| 2006 2150 OoOO4 S8?1 o811.- PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 3. Service Type Cl Certified Mait. ©) Express Mall . CO Registered (CI Retum Receipt for Merchandise ‘ O insurad Mail = C.0.D. 4, Restricted Delivery? (Extra Fee) US. Postal Servicem CERTIFIED MAIL..:: (Domestic Mail Only; No insuran® A SENDER: COMPLETE THIS SECTION m Complete items 1,2, and 3. Also complete jtem 4 if Restricted Delivery is desired. For delivery information visit our we 8 Printyour name and address on the reverse oO F - I Cc | A so that we can.retum-the card to you. . 1 Attach this card to the back of the mailpiece, ; oron the front if space permits. 14, Article Addressed to: O..18 ‘sivery ‘address diffarg if YES, enter delivery 2 Corlified Fee Retum Reciept Fas (Endorsement Required) Restricted Delivery Feo (Endorsament Required) ‘Total Postage & Foes | Fg, Service Type “EA Certified’ Mat 1 Express Mall te "(Cl Registered’. leturn Receipt for Me handise Aonuth [Tne woe ‘Insured Mal C1c.0.D.. Bax No, 7002 2410 0001 4232 015e or. re (2 Articla Numbe BPs > (Transfer fram service label)” "PS Form 3811, August 2001. Domestic reste Raum Rca 6. oo 2AGPREO3-Z-0985 Nan PS Form 3800, June 2002 U. S. Postal Servicen at CERTIFIED MAIL, RE¢ SENDER: COMPLETE THIS SECTION m (Domestic Mail Only; No Insurance . Complete items'1, 2; and 3: Also complete ~ A we; tute 3 ( nu For delivery information visit our website : tan 4 Rested 3 livery is decred, 2 iS) " , I m oF F I C {. A L so that we can return the card to you. (sae of Da en { qu § Attach this card to the’back of the mailplece, eRe , "Postage | $ ' gr on the front if space permits, “Tves A aa) H D;'Is delivery addrpss differant from Tem 19 fas, = Certified Fae ‘4. Ariicie Addressed to: | IfYES, enter délivery address below: “TINo R o (endareomont Heguled) Xx Ami { 1 Restricted a (Eames oars S545 Nw 44 W ru Total Postage & Fees $ CaCemut Crook - E rv a) 4363 — mu 7 . 8, Service Type a Ci Ceriified Mail 1 Express Mail fe hy _ ray 41/4/00 0) : . Cl Registered C1 Retum Recelpt for Merchandise — . Olinsured’Mail 01 G.0,D. ‘Giyy, Ls page hla Eos 7002 2420 o001 4232 Lb. PS Form 3800, June 2002 wnat tom Service Taba!) “PS Form 3811, August 2001 Domestic Rletum Receipt QA C, | BAGPRI-03-2-0985 “|sticted Delivery? (Extra Fea) 1 Yes

Docket for Case No: 07-005153