May 28 2009 14:50 MAY-28-2889 16:83 AGENCY HEALTH CARE ADMIN 856 921 4158 P22 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2009004594 NORTHWEST CARE CENTRE, INC., d/b/a NORTHWEST CARE CENTRE Il, 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 Northwest Care Centre, Inc., d/b/a Northwest Care Centre JI (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2008), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of two thousand dollars ($2,000.00) based upon one cited State Class II deficiency pursuant to § 429.19(2)(b), Florida Statutes (2008), and the imposition of a survey fee of five hundred dollars ($500.00) pursuant to the provisions of § 429,19(7), Florida Statutes (2008) for a total assessment of two thousand five hundred dollars ($2,500.00). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and Chapters 408, Part IJ, and 429, Part I, Florida Statutes (2008). 2. Venue lies pursuant to Florida Administrative Code R. 28-106,207. May 28 2009 14:51 MAY-28-2889 16°83 AGENCY HEALTH CARE ADMIN 654 921 4158 P23 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 Chapters 408, Part II, and 429, Part J, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 16-bed assisted living facility located at 802 71st Street, N.W., Bradenton, Florida 34209, and is licensed as an assisted living facility, license number 8425. 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 Jaw, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A~5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel independently in the community. (d) 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. (e) A written record, updated as May 28 2009 14:51 MAY-28-2889 16:84 AGENCY HEALTH CARE ADMIN 856 921 4158 P24 needed, of any significant changes as defined im 58A-5,0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services, Rule 58A-5.0182, Florida Administrative Code. 8. That on March 16, 2009, the Agency conducted a complaint investigation (CCR #2009003041) of the Respondent facility. . 9. That based upon the review of records and interview, Respondent failed to provide care and services appropriate to the needs of one (1) of four (4) sampled residents in regards to a staff member who was identified as not having a valid driver's license or current auto insurance, departing the Respondent facility with a resident in a vehicle, and subsequently Jeaving the resident, who lacked the capacity to exit from or roll down the windows of the vehicle, unsupervised on a hot day; the same placing the vulnerable resident's health at risk and in violation of the minimum standards of law. 10. That Petitioner’s representative interviewed Respondent’s administrator on March 16, 2009 who indicated as follows: a. An incident cecurred on October 10, 2008 involving resident number four (4) and staff member number one (1); b. Staff member number one (1) was providing companion services to resident number four (4); c. Staff member number one (1) admitted to leaving resident number four (4) in a car parked in a parking lot for an unknown period of time while the staff member ran into a Dollar General store; MAY-28-2889 16:84 May 28 2009 14:51 AGENCY HEALTH CARE ADMIN 856 921 4158 Resident number four (4) was left unsupervised in a hot car by staff member number one (1); Resident number four (4) lacked capacity to roll down windows of the vehicle or to exit the vehicle; Police were called to the site of the incident; The respondent did not complete any incident reports regarding this incident; The Respondent's staff nurse on duty at the time did not document the incident or any assessment of resident number four (4) upon the resident’s return to the facility after the resident had been left unsupervised in a hot vehicle; She was unaware at the time of the incident that staff member number one (1) did not have a current driver's license or valid auto insurance at the time of the incident which was two (2) and one-half (1/2) months after the auto insuranec on record had expired ll. That Petitioner’s representative reviewed Respondent’s records regarding resident number four (4) during the survey and noted as follows: a. d. The resident’s Health Assessment, dated March 3, 3008, identified diagnoses of Mental Retardation; Downs Syndrome; Alzheimer's; and Seizures; Identified physical limitations were "Impaired-previous strokes." All activities of daily living were identified by the health care provider as Tequiring either supervision or needing assistance, Absent from the records was any indicia of the incident of October 10, 2008. 12. That Petitioner’s representative reviewed Respondent’s personnel records regarding staff member number one (1) during the survey and noted as follows: P.25 MAY-28-2889 16:84 May 28 2009 14:52 AGENCY HEALTH CARE ADMIN 856 921 4158 The staff member had a date of hire of January 2008; A copy of the staff member's driver's license was on file which indicated an expiration of April 11, 2011; A copy of an auto insurance card was on file which indicated an expiration of July 28, 2008; The job description for a Residential Aide, signed January 11, 2008 by staff member number one (1) indicated “Certificates, Licenses, and Registrations required: Automobile Insurance/ Registration and License, 13. That the above reflects Respondent's fatlure to provide care and services appropriate to the needs of residents in Respondent’s failure to: a. Ensure that staff members are appropriately licensed and insured to transport Tesidents; . Ensure that a resident entrusted to Respondent’s care is not left unsupervised in a hot vehicle without the means to escape or otherwise react to needs; Ensure that the resident was assessed for injury, physical or psychosocial, after having been left unsupervised in a hot vehicle by Respondent’s agent; Ensure that the a resident’s health care provider and family or responsible party were notified of the significant change of a resident being left unsupervised in a hot vehicle without the means to escape or otherwise react to needs; Ensure that documentation of major incidents were maintained for the review of regulators, family, and health care professionals. 14. That the above reflects Respondent’s failure to assure that care and services were provided where Respondent failed to provide appropriate care and supervision resulting in a P.26 May 28 2009 14:52 MAY-28-2889 16:85 AGENCY HEALTH CARE ADMIN 856 921 4158 P.2? resident’s transport by unlicensed, uninsured staff, the resident being left in a vehicle in hot weather without the means to escape the heat or meet other self-care needs, and the failure to assess the resident for needs, or notify relevant parties of the event. 15. 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. 16. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2008). 17. That the Agency provided a mandated correction date of April 16, 2009. WHEREFORE, the Agency intends to impose an administrative fine in the amount of two thousand dollars ($2,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2008). co I 18. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. That pursuant to Section 429.19(7), Florida Statutes (2008), in addition to any administrative fines imposed, the Agency a assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2008), to verify the comection of the violations. 20, That on or about March 16, 2009, the Agency completed a complaint investigation at the Respondent Facility that resulted in a violation that is the subject of the complaint to the Agency. May 28 2009 14:52 MAY-28-2889 16:85 AGENCY HEALTH CARE ADMIN 856 921 4158 P.28 21. ‘That pursuant to Section 429.19(7), Florida Statutes (2008), such a finding subjects the Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or $500.00, 22. That Respondent is therefore subject to a complaint survey fee of five hundred dollars (8500.00), pursuant to Section 429.19(7), Florida Statutes (2008). 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, pursnant to § 429.19(7), Florida Statutes (2008). Respectfully submitted this “CS day of April, 2009. Fila Bar’ No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 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. May 28 2009 14:53 MAY-28-2889 16:65 AGENCY HEALTH CARE ADMIN 856 921 @158 P.29 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7008 0500 0001 0420 5109 on April 272 2009, to Pamela Anne Thomas, Esq,, counsel for Respondent, at Post Office Drawer 810, Tallahassee, FL 32302. Copies furnished to: Pamela Anne Thomas, Esq. | Kathleen Varga Thomas J. Walsh Il, Esq. Counsel for Respondent Facility Evaluator Supervisor Agency for Health Care Admin. Post Office Drawer 810 Agency for Health Care Admin, | 525 Mirror Lake Drive, 330G Tallahassee, FL 32302 525 Mirror Lake Dr. N, 4th Floor | St. Petersburg, Florida 33701 (U.S. Certified Mail} St. Petersburg, Florida 33701 Interoffice (Interoffice) May 28 2009 14:53 MAY-28-2889 16°86 AGENCY HEALTH CARE ADMIN 856 921 4158 P.38 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: NORTHWEST CARE CENTRE, INC., CASE NO: 2009004594 d/b/a NORTHWEST CARE CENTRE IIE 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 tight to contest the Agency's proposed action and a Final Order will be issued, Please use this form unless you, your attomey or your representative prefer to reply in accordance with Chapter]20, Florida Statutes (2008) 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 | 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 Adyinistrative 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 [ request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. May 28 2009 14:53 MAY-28-2889 16°86 AGENCY HEALTH CARE ADMIN 856 921 4158 P.ai 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. Astatement 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 hone. 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: A TOTAL FP.31

Docket for Case No: 09-002942