10/84/2018 23:39 9847976372 STEPHENS __ ne, PAGE 83 “ STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, ° « Petitioner, Case No. 2010009976 vs, STEPHENS MEMORIAL HOME, INC,, d/b/a STEPHENS MEMORIAL HOME, Respondent, / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and fila this Administrative Complaint against STEPHENS MEMORIAL HOME, INC., d/b/a Stephens Memorial Home (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2010), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of three thousand dollars ($3,000.00) based upon one (1) State Class Il deficiency pursuant to § 429.19(2)(b), Florida Statutes (2010). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 aud Chapters 408, Part U, and 429, Part I, Florida Statutes (2010). 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 Received Ti midtbclaber B602d20 68M Ap. BR iaion of Administrative Hearings. 10/84/2018 23:39 9847976372 STEPHENS PAGE @4 facilities and enforcement of all applicable state statutes and rules governing assisted living facilitics pursuant fo the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-S, Florida Administrative Code. | ‘ 4, Respondent operates a 15-bed assisted living facility located at 5805 Datil Pepper Road, St. Augustine; Florida 32086 and is licensed as an assisted living facility, license number 10189. 5, Respomtent 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 paragraphe (1) through (5) as if fully set forth herein. 7. 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 a facility. Every resident of a facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with duc recognition of. personal dignity, individuality, and the need for privacy. §429.28(1), Florida Statutes (2010) 8. That on August 26, 2010, the Agency conducted an unannounced complaint investigation (CCR# 2010008088) of the Respondent's facility. 9. That based on observation and interviews with residents and the owner/administrator, the facility failed to treat 3 of 15 sampled residents, #2, #4, and #5 with respect and dignity. Resident #2 Received Time Oct. 18. 2010 12:16PM No, 5892 10/04/2018 23:39 9847976372 STEPHENS PAGE @5 10. Observation of Resident #2 at 3:00 PM on 8/26/10 revealed she/he was seated at the dining roam table rubbing her/his cyes with a Kleenex. The resident dropped the soiled Kleenex on the floor and it fell underneath the dining room table. s ” 11. The ownes/administrator walked over to the resident and told him/her in a very loud, authoritative voice to "pick it up." She stated, "I saw you drop it, now pick it up!" 12. Resident #2 yelled back, “it is not mine and I am not going to pick it up. " The owner stated, "YES YOU ARE!" This exchange went on for approximately 1 minute and the owner finally picked it up and threw it in the trash. 13, This exchange took place while 8 other people watched and the resident seemed quite embarrassed. Resident 14. Observation of Resident #4 in heihis room at 1:45 PM on 8/26/10 revealed she/he was seated in a chair, which was located beside the bed. 15. When interviewed about why she/he did not come out of the room for lunch or join others in the scheduled activities, she/he stated that she/he did not want to be bossed around by the owner, was not able to choose what foods she/he wanted to eat, and none of the activities interested her/him. Consequently, she/he remained in the room all day and evening. 16. The owner entered Resident #4's room and stated, "You can't believe anything she/he tells you, she is totally confused." The resident heard this statement and became viaibly upset. The resident stated, "T am not crazy and everything I told her was the truth.” Resident #5 17. Observation of Resident #5 at 10:30 AM on 8/26/10 revealed she/he was seated in his/her room packing to leave. The resident stated she/he was not crazy and was ready to return home to the family. The owner stated, "I have told her/him a number of times that her /his family cannot Received Time Oct. 18. 2010 12:16PM No. 5892 ; 19/04/2018 | 23:39 3047976372 STEPHENS PAGE 46 take care of her/him and she/he is not going anywhere." ‘The resident became upset. At 3:30 PM, the resident showed the surveyor a business card of her/his family member and requested the surveyor called them as soon as possible to let them know she/he was ready to leave this facility and retum home. The resident stated, “they try to make me feel like I am crazy, but you can tell by talking to me and reading my medical chart that I am not crazy, can't you?" 18. That Class “IT” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or seourity of the clients, other than class I violations. The agency shall impose an administrative fine as provided by law for a cited class If violation. A fine shall be levied notwithstanding the correction of the violation, 19, That the Agency cited the Respondent for a Class II violation in sccordance with Section 429.19(2\(b), Florida Statutes (2009), 20. ‘That the Agency provided a mandatory correction date of August 29, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the ammount of three thousand dollars ($3,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2010). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) . Make factual and legal findings in favor of the Agency on Count I; (8) Recommend an administrative fine against Respondent in the amount of $3,000; (C) Assess attorney's fees and costs; and. @) Grant all other general and equitable relief allowed by law. Received Time Oct. 18. 2010 12:16PM No. 5892 _ 29/04/2018 23:39 ° 9047976372 STEPHENS PAGE 27 a Respondent is notified that it bas 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, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (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. , Respectfully submitted this .4__ day of October, 2010. 2 (- “a Carlton Enfinger Fla. Bar.0793450 Agenoy for Health Cafe Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.412.3640 (office) 850.921.0158 (fax) CATE RVI 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Retum Receipt No. 7001 0360 0003 3808 3215 to Facility Administrator and Registered Agent Brenda Stephens, Stephens Memorial Home, $805 Datil Pepper Road, St. —_ Augustine, Florida 32086 on October 2, 2010: Copy furnished to: Robert Dickson, FOM Received Time Oct. 18 2010 12:16PM No. 5892 U Postage Certified Fee Postmark Here {Endorsement Requized) Restricted Deliver (Endorsement pie) Total Postage & Fees wn A mu m oO ao co m a Return Receipt Fee oO ao [ioe] fa m a Rasa Sepa). ‘AQ eel oy i Streat, Apt Ne ' tl] or PO’ Box No, [we] BES born 3800, Jal Lary COMPi.ETE THIS SECTION ON DELIVERY © Agent 1 Addressee } TOPO D, Is delivery address different from item 17. Ol Yes @ 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 on the front if space permits. BU Re Eivedfoy (Printed Name) mel £4 SL2 “> 1. Article Addressed to: If YES, enter delivery address below: C1. No Brenda Sle (hens Adnit boy Sy. : \ een PVErDs Wenge, rN Re jl Sos he . rene Type : ~ Certified Mall 1 Express Mall po i ANCL Pegoss & @yper Bondy NSN Ako . W D Registered" (i Return Receipt for Merchandise, OO Se an RAGED Cl insured Mail (1. 6.0.D. C1 Yes 4, Restricted Delivery? (Extra Fee) 7001 0360 0003 3808 3215 PS Form 3811, February 2004 Domestic Return Recelpt

Docket for Case No: 10-009859