| ’ STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE D 1. 0 q 24 ADMINISTRATION, Petitioner, v. | CASE No. 2008009072 HARBOR VIEW ACRES, INC., Respondent. | / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, HARBOR VIEW ACRES, INC., (hereinafter “the Respondent”), pursuant to section 120.569 and 120.57, Florida Statutes (2008), and alleges as falows NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of five hundred dollars ($500.00) against the Respondent, the licensee of an assisted living facility, based upon a repeat offense, Class nt deficiency, pursuant to Section 429.71 (1)(c) Florida Statutes (2008). JURISDICTION AND VENUE 2. The Court has jurisdiction over the subject matter pursuant to Sections 20.22(2)(f), 120.569-.57, Florida Statutes (2008) and Chapter 429, Part II, Florida Statutes (2008). | \ 3. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Florida Statutes (2008), Chapter 429, Part II, Florida Statutes (2008) and Chapter 58A-14, Florida Administrative Code (2008). 4. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2008). | PARTIES 5. The Agency is the regulatory authority responsible for licensure and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2008) and Chapter 58A-5, Florida Administrative Code (2008). 6. The Respondent operates a 25 bed Assisted Living Facility located at 24450 Harborview Road, Port Charlotte, Florida, and is licensed as an assisted living facility, under license number 7257. | 7. Respondent was at all times material, required to comply with all applicable federal and state regulations, statutes and rules. | COUNT I (Tag A812) 8. The Agency re-alleges and incorporates paragraphs one (1) through seven (7) as if fully set forth herein. | 9. That on or about June 29, 2006, the Agency conducted a biennial survey of Respondent’s facility. 10. Based on the record reviews, observation, and interviews, the facility failed to ensure that therapeutic diets ordered by residents’ physicians were prepared and served to two of three sampled residents and one random sampled resident. ll. The findings include: 1. Resident #1 was admitted to the facility on January 29, 2004 and per ‘Department of Elderly Affairs Form 1823, a physician’s order was written ‘for a mechanical soft diet on February 2, 2006. Observation during the noon meal on June 29, 2006 revealed this resident received a regular diet of chunks of beef tips with noodles, corn, bread and butter, and vanilla 2 cake with frosting, and not the mechanical soft diet as ordered. Interview with the Administrator at approximately 12:30 p.m. revealed the facility |can provide a mechanical soft diet as ordered. 2. ‘Resident #3 was admitted to the facility on April 8, 2003 and per the ‘Department of Elderly Affairs Form 1823, a physician’s order was written for honey thick liquids on January 4, 2005. Observation at 10:00 a.m. passing out of morning snacks, revealed unthickened tomato juice. At the ‘noon meal, the resident received a glass of water and a glass of cranberry juice, both unthickened. Interview with the Administrator at approximately 12:30 p.m. revealed the facility has a “Thick-It” in the facility to provide thickened liquids as ordered. 3. Per the Department of Elderly Affairs Form 1823, for random sampled Resident #4, a physician’s order was written for the resident to have a ‘mechanical soft diabetic diet with no added salt. Observation of the noon meal revealed the resident received chunks of beef tips with noodles, corn, bread and butter, and vanilla cake with frosting. The staff person did not serve the proper foods according to the resident’s therapeutic diet and could not offer an explanation of why the resident’s needs were not met. | 4. ‘The staff person on duty reported that special diets or restrictions were ‘written on a board in the kitchen. Observation of the board in the kitchen ‘revealed random sample Resident #4 was the only listing with restrictions for “no sugar”. 12. The Agency determined that above constitutes a violation of Rule 58A- 5.020(2)(e), Florida Administrative Code (2008) and cited the Respondent for a Class III deficiency. | 13. The Agency provided the Respondent with a mandatory correction date of July, 29, 2006. | 14. That oh or about August 15, 2006, the Agency conducted a follow-up of the facility and found that the violation was corrected. 15. That on or about June 23, 2008, the Agency conducted another biennial survey of the Respondent’s web | 16. Based on observation, review of the therapeutic diets served, and interviews with facility staff, the facility failed to serve 1 of the 4 sampled residents the therapeutic diet prescribed by the health care provider. 17. The findings include: 1. | Observation on June 23, 2008 at 11:30 a.m. revealed the resident was served her lunch on a small dinner plate. Her lunch meal was chunks of ‘beef i in a stroganoff sauce, noodles, 1/2 slice of buttered bread and coleslaw with tomatoes. 2. The resident's diet order was reviewed and it specified a regular diet with ground meat and no raw vegetables. 3. Review of the erase board in the hallway connecting the kitchen revealed the resident's ground meat was not on the board, but small portions was listed. 4. | During an interview with the cook on June 23, 2008 at 11:45 a.m., she ‘revealed that she knew the resident's diet order called for ground meat. There was no explanation why the resident received a small plate and a ‘smaller portion. 18. The above constitutes a repeat violation of Rule 58A-5.020(2)(e), Florida Administrative Code. | 19. —- Rule 58A-5.020(2)(e), Florida Administrative Code, (2008) states as follows: 58A 5.020 Food Service Standards. (2) DIETARY STANDARDS (e) Therapeutic diets shall be prepared and served as ordered by the health care provider. 1. Facilities that offer residents a variety of food choices through a select menu, buffet style dining or family style dining are not required to document what is eaten unless a health care provider’s order indicates that such monitoring is necessary. However, the food items which enable residents to comply with the therapeutic diet- shall be identified on the menus developed for use in the facility. 2. ‘The facility shall document a resident’s refusal to comply with a therapeutic diet and notification to the resident’s health care provider of such réfusal. If a resident refuses to follow a therapeutic diet after the benefits are explained, a signed statement from the resident or the resident’s responsible party refusing the diet is acceptable documentation | ofa resident’s preferences. In such instances daily documentation is not necessary. | | 20. The Agency determined that above constitutes a violation of Rule 58A- 5.020(2)(e), Florida Administrative Code, (2008), and cited the Respondent for a Class III | deficiency. | | 21. =‘ This is a repeat violation. The facility was previously cited for the same violation at a June 29, 2006 biennial survey, that violation was corrected by the August 15, 2006 follow- up survey as noted above in paragraphs nine (9) through thirteen (13). 22. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, requests the Court to impose an administrative fine for a cited uncorrected repeat | Class III violation in the amount of five hundred dollars ($500.00) against the Respondent, an assisted living facility, pursuant to Section 429.71(1)(c) Florida Statutes (2008). 23. Section 429.71(1)(c) Florida Statutes (2008) states as follows: Class III violations are those conditions or practices related to the operation and maintenance of an adult family-care home or to the care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of residents, other than class I or class II violations. |A class III violation is subject to an administrative fine in an amount not less than $100 and not exceeding $250 for each violation. A citation for a class III violation shall specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no civil penalty shall be imposed, unless it is a repeated offense. CLAIM FOR RELIEF WHEREFORE, the Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, respectfully requests the Court to grant the following relief: 1. Enter findings of fact and conclusions of law as set forth in the complaint. 2. Impose an administrative fine of five hundred dollars ($500.00). 3. Order any other relief that the Court deems just and appropriate. | NOTICE Respondent ig notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Ageney Clerk, at the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, (850) 922-5873. | If you choose to hire an attorney, you have the right to be represented by an attorney in this matter. | RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (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. , 2008. Respectfully s submited this . Agency for Health Care Administration “9727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint and Election of Rights form was served to Harbor View Acres, Inc., 24450 Harborview Road, Port Charlotte, Florida 33980, by U.S. Certified Mail, Return Receipt No.7004 2890 0000 5526 8688, to Denise Dayes, 5827 Woodlands Boulevard, Tamarac, Florida 33319, Return Receipt No.7004 2890 0000 5526 8442 and to Dana Gilreath, Administrator, Harbor View Acres, Inc., 24450 Harborview Road, Port Charlotte, Florida 33980, U.S. Certified Mail, Return Receipt No.7004 2890 0000 5526 8503 on this 4 Hor |, Blovid’’ Bar Number 0768715 ‘4 Cotnsel for Petitioner Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 | . Tallahassee, Florida 32308 Copy furnished to: Harold Williams, FOM (Interoffice Mail) f U.S. Postal Service. CERTIFIED MAIL. RECEIP ronromesaree|§ | a “s Fr (Pomestic Mail Only; No insurance Coverages ovided). 2 For. delivery information visit our website at “USE oO a| OFFICIAL US wn " rom ]s | ao Fee 2 cmm| |, Return Receipt Fee Here S tmnt | o icted Delivery Fee i oO fu r a a ~ Sent Te ANA won it ~ o7 PO Box No, ¥ SENDER: COMPLETE THIS SECTION ® Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ™@ Print your name and address on the reverse So that we can return the card'to you. ™ Attach this card to the back of the mailpiece, or a: the front if space permits. 1. Article Addressed to: Dasa Giceeate HARBOR View Actes, Ince B. Received by (Printed Name) pile p D. Is delivery address different from item 17 Cl Yés {f YES, enter delivery address below: © _O.No ZYUSS WAeBoRViEw RO £ . Wer CuArorré, fe 339¥0 3.. Service Type JS Certified Mail. 1 Express Mail CO Registered C Return Receipt for Merchandise O insured Mail Ocop. 4, Restricted Delivery? (Extra Fee) 1 Yes 7004 2850 nooo 5526 8503 Domestic Return Receipt 2," Article Number . (Transfer from service label) */ £} OG ; PS Form 3811, February 2004 —_— 102595-02-M-1540 ; el ‘Service: CERTIFIED MAIL. RECEIP (Domestic Mail Only; No Insurance Covera vided) For delivery information visitour. Website at www.usps.coms OFFICIAL USE Postmaric Return Receipt Fee Here (Eridorsement Required) Restricted Delivery Fee (Endorsement Required) 2004 7a90 Of00 552b &b&d AR BORNE Ww ACRES. TOC See uss Htley ho eee . See SPLOT E 3450 eo) 0G) 2) Seo Reverse tot insitucubns. SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and addréss on the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. B. Received by ( Printed Name) LYS antena_ 1. Article Addressed to: Larson Wiew Aczes, jue, AAAS @ HAR BORN Wey KoA 1s ey errs Royle, Fu 3539 70 3. Service Type tl Certified Mait ‘ C1 Express Mail a OC Registered (1 Return Receipt for Merchandise C1 insured Mail = C.0.D. 4. Restricted Delivery? (Extra Fee) O Yes 2, Article Number (Transfer from service label) 7004 2890 OOOO 5526 4b PS Form 3811, February 2004 Domestié Return Receipt 402595-02-M-1540

Docket for Case No: 09-000929