STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, : Case No. 2011005989 vs. : 2011005987 2011005983 MARGIE BROWN, d/b/a BROWN’S HARBOR HOUSE, 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 Margie Brown, d/b/a Brown’s Harbor House (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2010), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an assisted living facility, impose an administrative fine of totaling twelve thousand five hundred dollars ($ 12,500) pursuant to §429.19(2)(b) and (c), Florida Statutes (2010). JURISDICTION AND VENUE L. The Agency has jurisdiction pursuant to §§ 20,42, 120.60, and Chapters 408, Part II, 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 facilities and enforcement of all applicable state statutes and rules governing assisted living Filed July 7, 2011 12:55 PM Division of Administrative Hearings gi facilities pursuant to the Chapters 408, Part Il, and 429, Part I; Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 4, Respondent operates a 11-bed assisted living facility located at 1619 Monroe Sheffield Road, Chipley, Florida 32428, and is licensed as an assisted living facility, license number 9555. 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 (Tag A001) 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, the requirements of part If of chapter 408 apply to the provision of services that require licensure pursuant to this part and part II of chapter 408 and to entities licensed by or applying for such licensure from the agency pursuant to this part. A. license issued by the agency is required in order to operate an assisted living facility in this state. §429.07(1), Florida Statutes (2010) 8. That on September 17, 2010, the Agency conducted an unannounced operation spot check of the Respondent facility. 9, That based on observation, interview, and record review, it was determined that the facility was not licensed to provide services. Impacting 5 of 5 residents (#1, #2, #3, #4, #5) 10, That on 9/17/2010 at approximately 9:15 AM CST, an Operation Spot Check was conducted at the licensed facility. During a tour of the facility and grounds, two small mobile homes were observed. 11. That the first mobile home was entered by the Investigators from the Attorney General's office and the AHCA surveyor. The mobile home was noted to be occupied by 2 persons. The mobile home appeared in extreme disrepair. 12. Thata male resident (#1) was observed at 9:30 AM CST seated on a couch smoking a cigarette. He stated he had been living in the mobile home with his wife (resident #2) for approximately 2 years and 4 months. He stated the couple paid the owner of the trailers . $1600.00 monthly for rent. Resident #1 stated he received all his meals and medications at "Mama's house." The resident stated Mama kept all his medications in a locked closet in her house. 13, That the second mobile home was entered at approximately 10:00 AM CST and also was observed to be in extreme disrepair, Resident #3 was observed standing in the living room area and he stated he had been living in the trailer for 4 years with resident #4. Resident #3 stated he paid "Mama" $650.00 monthly and received $24.00 in spending money. He stated he received his meals and medications from "Mama's house" and that Mama and her son helped take him and resident #4 to doctor appointments and obtained his medications from the pharmacy. Resident #3 stated Mama's son had taken resident #4 to a doctor's appointment in Pensacola "this morning." : 14, That the main house was entered by Investigator's with the Attorney General's office and the AHCA surveyor at approximately 10:30 AM CST. Resident #5 was observed walking around the common room area adjacent to the kitchen. He stated he lived in the side porch area of the main house and received his medications and meals from "Mama." 15. At approximately 11:00 AM CST an interview was conducted with the licensee of Brown's Harbor House and owner of the 2 mobile homes. She stated she had 5 people that she chad as "private pay." She stated she kept their medications in a locked closet in her house, She unlocked the closed and revealed the medications for residents #1, #2, #3, #4, and #5. She also confirmed that she and her family provided transportation to medication appointments and picked up the resident's medications from the pharmacy. 3 16. At approximately 12:00 PM CST, the State Fire Marshall and the County Code inspector surveyed the 2 mobile homes and stated they were "unsafe" and should not be occupied. The Investigators from the Attorney General's office contacted The Department of Children and Families, 17, At approximately 2:00 PM CST, the Licensee of Brown's Harbor House (owner of the mobile homes) was served a Cease and Desist order from AHCA and she verbalized understanding. 18. Thatthe same constitutes a deficiency pursuant to §429.07(1), Florida Statutes (2010), WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent. COUNT II (Tag 1001) 19. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 20. That pursuant to Florida law, an assisted living facility that was initially licensed prior to the effective date of this rule must comply with the rule or building code in effect at the time of initial licensure, except that any part of the facility included in additions, modifications, alterations, refurbishing, renovations or reconstruction must comply with the codes and standards referenced in subsection (1) of this rule. Determination of the installation of a fire sprinkler system in an existing facility must comply with the requirements described in Section 429.41, ES, Fla. Admin, Code R. 58A-5.023(2) 21. That pursuant to Florida law, it is the intent of the Legislature that rules. published and enforced pursuant to this section shall include criteria by which a reasonable and consistent quality of resident care and quality of life may be ensured and the results of such resident care 4 # ¥ may be demonstrated, Such rules shall also ensure a safe and sanitary environment that is residential and non-institutional in desi gn or nature. It is further intended that reasonable efforts be made to accommodate the needs and prefererices of residents to enhance the quality of life in a facility. The agency, in consultation with the department, may adopt rules to administer the requirements of part II of chapter 408. In order to provide safe and sanitary facilities and the highest quality of resident care accommodating the needs and preferences of residents, the department, in consultation with the agency, the Department of Children and Family Services, and the Department of Health, shall adopt rules, policies, and procedures to administer this part, which must include reasonable and fair minimum standards in relation to: {a) The requirements for and maintenance of facilities, not in conflict with the ) provisions of chapter 553, relating to plumbing, heating, cooling, lighting, ventilation, living space, and other housing conditions, which will ensure the health, safety, and comfort of residents and protection from fire hazard, including adequate provisions for fire alarm and other fire protection suitable to the size of the structure. Uniform firesafety standards shall be established and enforced by the State Fire Marshal in cooperation with the agency, the department, and the Department of Health. §429.41( 1), Florida Statutes (2010) 22. That on September 17, 2010, the Agency conducted an unannounced operation spot check of the Respondent facility, 23. That based on interview and record review, it was determined that the facility failed to maintain a safe environment. 24. That at approximately 1:30 PM CST the State Fire Marshall concluded that the facility did not have a functional fire panel or sprinkler system. He informed the owner of the facility that-a "fire watch" would be necessary until the problems could be resolved and gave the Owner a correction date of 72 hours (9/20/2010). . 25, An interview was conducted with the State Fire Marshall at this time and he stated the facility's fire panel "showed a trouble signal" and the sprinkler tank was empty. He stated the facility had not had their fire detection system inspected since 2008. 26. That the Agency determined that the above constitutes grounds for the imposition of a Class II deficiency in that it relates to the operation and maintenance of a facility or the personal care of residents which directly threatens the physical or emotional health, safety, or security of resident, 27. That the Agency provided Respondent with a mandatory correction date of September 20, 2010, ° 28. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2010). WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Fla. Stat. (2010). COUNT IH (Tag A104) 29. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 30. That pursuant to Florida law, the facility shall maintain written business records using generally accepted accounting principles as defined in Rule 61H1-20.007, F.A.C., which accurately reflect the facility’s assets and liabilities and income and expenses. Income from residents shall be identified by resident name in supporting documents, and income and expenses from other sources, such as from day care or interest on facility funds, shall be separately 6 identified. Fla. Admin. Code R. 58A-5.021(2) 31, That on November 9, 2010, the Agency conducted a biennial licensure survey of the- Respondent facility. 32. Thatbased on interview the facility failed to maintain written business records which accurately reflect the facility's assets, liabilities, income from residents and expenses. 33, . That the surveyor requested the facility's financial records to include accounting procedures, income by source, expenses and resident funds three times on 11/9/2010. 34, During an interview with the administrator on 11/9/2010 at approximately 11:50AM the administrator stated the only financial records they maintain are resident account logs for Optional State Supplementation recipients indicating they receive $54.00 per month personal allowance. 35. That Class “III” 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 indirectly or "potentially threaten the physical or emotional health, safety, or security of clients, other than class J or class II violations, The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. §408.813(2)(c), Florida Statutes (2010) 36. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 37. That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 38. That based on interview the facility failed to maintain written business records which accurately reflect the facility 's assets liabilities, income from residents and expenses, 7 39. Thatthe surveyor requested the facility 's financial records to include accounting ’ procedure, income by source, expenses, and resident funds on 12/28/2010, 40. . Thatthe Administrator produced a "Monthly Income and Expense Statement" for August, September and October 2010. The Administrator stated she "just went 3 months back". She was unable to produce a report for November. She stated that November was not completed. 41. Thatan interview was conducted with the Administrator and the Assistant Administrator on 12/29/2010 regarding the totals listed on the Monthly Income and Expense Statement. The reports produced for August, September and October were identical. 42. Thatthe Assistant Administrator said that these figures were only an estimation of the amount spent each month and not the actual amount spent. 43. That the ALF was unable to provide documentation, (such as receipts and payroll records), to support the ALF's assets and liabilities, despite repeated requests. 44. Thata review of the furnished monthly expense accounting revealed the ALF indicated that they spent "$3,500.00" on food monthly, however a review of the ALF food storage did not support this listed expenditure. 45. That on 12/29/2010 at 7:20 AM CST, the breakfast meal was observed being prepared by a staff member. The meal did not match the menu (which indicated bacon and eggs) and lacked any source of protein. The staff member was interviewed regarding this discrepancy and stated "we do not have any eggs and bacon," 46. That the same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 2011. 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), Fla. Stat. (2010). 8 COUNT IV (Tag A110) 47. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. That pursuant to Florida law, if the facility provides safekeeping for money or property, holds resident money or property in a trust fund; or if the facility owner, administrator, or staff, or representative thereof, acts as a representative payee; the resident or the resident’s legal . representative shall be provided with a quarterly statement detailing the income and expense records required under subsection (4), and a list of any property held for safekeeping with copies maintained in the resident’s file. The facility shall also provide such statement upon the discharge of the resident, and if there is a change in ownership of the facility as provided under Rule 58A-5.014, F.A.C. Fla. Admin. Code R. 58A-5.021(7)(a) 49. That pursuant to Florida law, any funds or other property belonging to or due to a resident, or expendable for his or her account, which is received by a facility shall be trust funds which shall be kept separate from the funds and property of the facility and other residents or shall be specifically credited to such resident. Such trust funds shall be used or otherwise expended only for the account of the resident. At least once every 3 months, unless upon order of a court of competent jurisdiction, the facility shall furnish the resident and his or her guardian, trustee, or conservator, if any, a complete and verified statement of all funds and other property to which this subsection applies, detailing the amount and items received, together with their sources and disposition. In any event, the facility shall furnish such statement annually and upon the discharge or transfer of a resident. Any governmental agency or private charitable agency contributing funds or other property to the account of a resident shall also be entitled to receive such statement annually and upon the discharge or transfer of the resident. 9 “nga §429.27(4), Florida Statutes (2010) 50. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 53. That based on interview the facility failed to provide a quarterly statement detailing the income and expenses for 7 of 11 residents the facility owner acts as a representative payee. (#2; 3, 5, 6,7, 8, 9) 56. That on 11/9/2010 at approximately 9:55AM the facility owner stated she is the representative payee of residents #2, 3, 5, 6, 7, 8 and 9, 57. An interview was conducted on 11/9/2010 at approximately 10:30AM with the facility owner, assistant administrator and the administrator. They all stated they do not maintain or provide quarterly statements or any accounting of the resident funds and all monies go into one account. 5 8. During an interview on 11/9/2010 at approximately 2:10PM resident #2 stated they do not reosive any financial statements from the facility. 59. During an interview on 11/9/2010 at approximately 2:15PM resident #8 stated they do hot receive any financial statements from the facility, 60. During an interview on 1 1/9/2010 at approximately 2:17PM resident #3 stated they do not receive any financial statements from the facility. 61. That Class “IIL” violations ate those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class IT violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation, A citation for a class III violation must specify the time within which the violation is required to be corrected. Ifa class IE] violation is corrected within the time specified, a fine may not be imposed. §408.813(2)(c), Florida Statutes (2010) 62. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 63. That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 64. That based on interview the facility failed to provide a quarterly statement detailing the income and expenses for 7 of 11 residents the facility owner acts as a representative payee, (#2, #3, #5, #6, 47, #8, #9) 65. Thatan interview was conducted with the facility owner on 12/29/2010, requesting the quarterly statement for the residents in which she is representative payee, the facility owner stated that they "haven't done that", says "never knew they had to”, 66. — An interview was conducted with both the Administrator and the Assistant Administrator on 12/29/2010. The Administrator and Assistant Administrator stated that there was no reason to provide quarterly statements to the residents because "they would not be able to understand them". 67. That the same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of J anuary 29, 2011 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), Fla. Stat. (2010). COUNT.V (Tag A310) 68. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 3 3 69. That pursuant to Florida law, pursuant to Section 429.24, ES. prior to or at the time of admission, cach resident or legal representative shall execute a contract with the facility which contains the following provisions: (a) A list of the specific services, supplies and accommodations to be provided by the ’ facility to the resident, including limited nursing and extended congregate care services if the facility is licensed to provide such services. Fla. Admin, Code R. 58A-5,025(1)(a) 70. That pursuant to Florida law, the presence of each resident in a facility shall be covered by a contract, executed at the time of admission or prior thereto, between the licensee and the resident or his or her designee or legal representative. Each party to the contract shall be provided with a duplicate original thereof, and the licensee shall keep on file in the facility all such contracts, The licensee may not destroy or otherwise dispose of any such contract until 5 years after its expiration. §429.24(1), Florida Statutes (2010) 71. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 72. That based on interview and record review the facility failed to list the Limited Mental Health services provided by the facility in the resident contract. 73. | That on 11/9/2010 the resident facility contract was reviewed. The contract failed to list the Limited Mental Health services provided by the facility. 74, This was confirmed by the assistant administrator. The administrator confirmed that all 11 residents received Limited Mental Health services. 75. That Class “III” 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 indirectly or 12 potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed, §408.813(2)(c), Florida Statutes (201 0) 76. ° That the Agency provided Respondent with a mandatory correction date of December 9, 2010. | 77. That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 78. That based on interview and record review the facility continued to fail to list the Limited Mental Health services provided by the facility in the resident contract. 79. ~ Thatan interview was conducted with the Administrator on 12/28/2010 at approximately 11:00 AM CST regarding the inclusion of Limited Mental Health Services to the resident's contract. The Administrator produced a document with a paragraph written to include Limited Mental Health Services but had yet to add it to the resident's contract, 80. The Administrator also admitted that she failed to notify the residents of this addition and failed to add this addendum to the contract and stated " I just prepared the book for the follow up." 81. That the same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429, 1902)(c) (2010) and the Agency provided a mandatory correction date of January 29, 201] 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), Fla. Stat. (2010). COUNT VI (Tag A518) 82. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 83. That pursuant to Florida law, facilities shall maintain the following minimum staff hours per week: Number ofResidents Staff Hours/Week 0-5 168 6-15 . 212 16- 25 : 253 26-35 294 36-45 335 46-55 375 56- 65 416 66-75 457 76-85 498 86-95 539° For every 20 residents over 95 add 42 staff hours per week. Fla. Admin. Code R. 58A- 5.019(4)(a)1 84. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 85. That based on observation and interview it was determined the ALF failed to maintain minimum staffing hours weekly based on a census of 11. 86. That on 11/9/2010 at approximately 10:00 AM CST the survey team made several requests for the facility's staffing schedule. 87. That the Administrator and Assistant Administrator produced 2 documents that revealed a single staff member worked 48 hours straight on Monday, Tuesday, and Fridays. 88. That when questioned about the work schedule the Assistant Administrator stated “oh that is not correct, I'll get you a correct one." 14 89. Thata second document was presented approximately one hour later that was exactly the same. Again the Administrator and Assistant Administrator stated that the document was not _ correct. ‘90. That the survey team then requested the facility's payroll for the past full work week. 91. That the Administrator failed to comply with that request and could not provide evidence of minimum staffing hours. 92. That the facility was noted to have a current census of 11 Limited Mental Health residents. 93. That the Agency determined that the above constitutes grounds for the imposition of a Class IT deficiency in that it relates to the operation and maintenance of a facility or the personal care of residents which directly threatens the physical or emotional health, safety, or security of resident, 94, That the Agency provided Respondent with a mandatory correction date of December 9, 2010, 95. That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 96. That based on observation, interview, and record review it was determined the ALF failed to ensure minimum staffing standards for a census of 11.. | 97. That the Administrator, Assistant Administrator and Owner were interviewed on 12/29/2010 at approximately 9:45 AM CST and the survey team requested evidence to support the last 7 days or staffing. 98. That the Administrator produced a dryease board with single initials ona daily basis, When questioned if the employee worked 24 hours straight. The Administrator responded "po" and then produced a "work schedule" that indicated shifts of 8 to 12 hours with several 15 employees per shift, however the schedule did not include any dates or months. The survey team requested any data such as payroll to support the hours and the owner responded "I pay them in cash". 99.. Thatthe Administrator, Assistant Administrator and Owner were requested to provide any supportive data to confirm the amount of staffing over the 2 day survey and were unable to provide any data to support staffing hours (such as payroll distribution or cash receipts). 100, Thatthe Administrator produced 3 months of financial records for August, September, and October 2010 and indicated an expenditure of $3,890.00 for each month for payroll. 101. Thatwhen asked how she arrived at that number, the ALF staff became angry and the survey team aborted the follow up. 102. During the 2 day follow up several staff members were interviewed regarding their staff hours and pay. The staff members refused to respond to survey questions. 103. That the same constitutes an uncorrected Class II offense as defined in Florida Statute 429,19(2)(b) (2010). 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), Fla. Stat. (2010). . | COUNT VII (Tag A619) 104. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 105. That pursuant to Florida law, centrally stored medications must be: 2. Located in an area free of dampness and abnormal temperature, except that a medication requiring refrigeration shall be reftigerated. Refrigerated medications shall be secured by being kept in a locked | container within the refrigerator, by keeping the refrigerator locked, or by keeping the area in 16 Nene which refrigerator is located locked. Fla. Admin. Code R. 58A-5.0185(6)(b)2 106. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 107. That based on observation the facility failed to ensure centrally stored medications were kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times and failed to ensure refrigerated medications were kept in a locked container within the refrigerator. 108. That an observation on 11/9/2010 at approximately 9:30AM revealed the door of the central storage closet for medications open and unattended for approximately 3 minutes. 109. During a tour of the kitchen on 11/9/2010 at approximately 9:00-9:30AM the refrigerator contained several vials of Humulin 70/30 insulin and Risperdal injections. The medications were not in a locked container and the refrigerator was not locked. 110. That Class “II” 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 indirectly or potentially threaten the physical or emotional: health, safety, or security of clients, other than class I or class IT violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class IIT violation must specify the time within which the violation is required to be corrected. If a class ILI violation is corrected within the time specified, a fine may not be imposed. §408.813(2)(c), Florida Statutes (2010) 110. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 111. . That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 17 112. ' That based on observation the facility failed to ensure that centrally stored medications were kept ina locked room at all times. 113. During the initial tour of the ALF on 12/28/2010 at approximately 09:15 CST, the medication room door was observed to be wide open. There were 4 residents sitting in the adjacent room watching television. An employee was at the side door sweeping. Inside the room there were medication bottles laying out on the desk, multiple bags containing patient medications and insulin syringes. 114. | The ALF kitchen was also noted open and medications were stored in the refrigerator inside a black metal box noted to be locked, however the key to the box was noted on a nail next to the refrigerator. 115. That the same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 2011 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), Fla. Stat. (2010). COUNT Vii (Tag A625) 116. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 117. That pursuant to Florida law, medications which have been abandoned or which have expired must be disposed of within 30 days of being determined abandoned or expired and disposition shall be documented in the resident’s record. The medication may be taken to a pharmacist for disposal or may be destroyed by the administrator or designee with one witness. Fla, Admin. Code R. 58A-5.0185(6)(e) 118. That on November 9, 2010, the Agency conducted a biennial licensure survey of the 18 Ses? Respondent facility. 119.. That based on observation and interview the facility failed to ensure medications which have expired were disposed of within 30 days of being determined expired. 120. During a tour of the kitchen on 11/9/2010 the refrigerator contained a sealed box of Risperdal injections with an expiration date of 2/2010. 121. Thatthe assistant administrator confirmed the medication was expired. 122, That Class “II” 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class IIL violation must specify the time within which the violation is required to be corrected, If a class II violation is corrected within the time specified, a fine may not be imposed. §408.813(2)(c), Florida Statutes (2010) 123. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 124, That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 125. That based on observation and interview the facility failed to ensure medications which have been abandoned were disposed of within 30 days of being determined abandoned. 126. During an observation on 12/28/2010 at approximately 11:40 CST, the refrigerator contained a locked medication box with a box/bottle of Haloperidol injectable labeled with a resident that had been discharged back in August 2010. 19 “ean” 127. Thatan interviewed was conducted, at the time of the observation, with the Administrator and Assistant Administrator. The Assistant Administrator stated that the resident left in August and that they "simply forgot" to send the medication back to the pharmacist. 128, That the same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429,19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 2011 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), Fla. Stat. (2010). COUNT IX (Tag A626) 129, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 130. That pursuant to Florida law, no prescription drug shall be kept or administered by the facility, including assistance with self-administration of medication, unless it is properly labeled | and dispensed in accordance with Chapters 465 and 499, F.S., and Rule 64B16-28.108, F.A.C. If a customized patient medication package is prepared for.a resident, and separated into individual medicinal drug containers, then the following information must be recorded on each individual container: : _— 1. The resident’s name; and 2. Identification of each medicinal drug product in the container. Fla. Admin. Code R. 58A-5.0185(7)(a) 131. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 132, That based on observation and interview the facility failed to ensure all prescription medications were properly labeled to include the practitioner's name, resident ' s name, date 20 Seaegpa dispensed, name and strength of drug, quantity of drug in container, directions for use, pharmacy name and expiration date. 133. Thaton 11/9/2010 2 vials of Humulin 70/30 insulin were observed. 134. That the insulin did not have a label to include practitioner name, resident name, date dispensed, directions for use or pharmacy name. The Administrator revealed the vials were resident #2's medication. 135. That the above reflects Respondent’s failure to ensure all prescription medications were properly labeled to include the practitioner’s name, resident’s name, date dispended, name and strength of drug, quantity of drug in container, directions for use, pharmacy name and expiration date. 136. That the Agency determined that the above constitutes grounds for the imposition of a Class II deficiency in that it relates to the operation and maintenance of a facility or the personal care of residents which directly threatens the physical or emotional health, safety, or security of resident, 137. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. | 138. That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 139. That based on observation and interview the facility failed to ensure all prescription medications were properly labeled to include the practitioner 's name, resident's name, date dispensed, name and strength of drug, quantity of drug in container, directions for use and pharmacy name. 21 140. That on 12/28/2010 at approximately 11:40 AM CST, a single vial of Humulin 70/30 insulin was observed. The insulin did not have a label to include the practitioner's name, resident name, date dispensed, directions for use or pharmacy name. 141. That on 12/28/2010 at approximately 11:40 AM CST, the Administrator revealed the medication vial belonged to resident #2. 142, That the same constitutes an uncorrected Class II offense as defined in Florida Statute 429.19(2)(b) (2010). 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), Fla. Stat. (2010). COUNT X (Tag A801) 143. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. . 144. That pursuant to Florida law, when food service is provided by the facility, the administrator or a person designated in writing by the administrator shall: (b) Perform his/her duties in a safe and sanitary manner. Fla, Admin. Code R, 58A-5.020(1)(b) 145. That on November 9, 2010, the Agericy conducted a biennial licensure survey of the Respondent facility. 146. That based on observation and interview it was determined the ALF failed to ensure sanitary food storage and preparation. 147, That on 11/9/2010 at 9:00 AM CST several packages of frozen Pork chops were observed on the kitchen counter thawing. The pork chops were again observed on the counter at 10:30 AM CST. 22 148. Thaton 11/9/2010 at 11:50 AM CST the central food pantry in the kitchen was observed, The pantry contained the ALF's standard food supply and emergency food storage. There were several bags/boxes of rice, bread crumbs, sugar, powdered milk and crackers that had areas that appeared to be chewed by rodents. 149, That the shelves contain rodent-like droppings and spilled food particles. The cans appeared dusty and some were bent. 150. An interview with the kitchen staff at this observation was conducted and she stated she was not aware any mice or rodents had been in the pantry. 151. That Class “III” violations are those conditions or occurrences related to the operation and niaintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class I violations. The agency shall impose an administrative fine as provided in this section for a cited class II] violation. A citation for a class a violation must specify the time within which the violation is required to be corrected. If-a class III violation is corrected within the time specified, a fine may not be imposed. §408.813(2)(6), Florida Statutes (2010) 152. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 153.. That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility, 154. That based on observation and interview it was determined the ALF failed to ensure sanitary food storage and preparation. 155. That on 12/28/2010 at approximately 10:15 AM CST the central pantry between the kitchen and laundry room was observed along with the owner of the ALF. The pantry contained the ALF's standard food supply and water stored in reused plastic containers. The shelves 23 contained rodent-like droppings throughout. 156. That the canned items were checked for expired dates and package integrity and revealed: Dented can of sliced beets, use by 11/30/2007 Picante sauce, use by 01/28/10 1 can of beans with chewed/shredded label suggesting rodent-like chew marks dented can of Kidney Beans Ranch-style black beans, use by 07/31/2008 opened undated bottle of BBQ sauce with instructions to refrigerate afler opening dented can of black beans, use by 03/2010 (4) 1 gt size Cheddar Cheese soup, use by 03/22/2007 1 can of Jellied Cranberry sauce, use by 09/21/2006 (4) 1 qt cartons of Roast Red Pepper Tomato Soup, use by 1 April 2007 1 can of cream corn rusted and shredded label Dented can cranberry sauce 1 can rusted /corroded Great Northern Beans 1 can Chick Peas, use by 07/26/2008, an additional rusted can of Chick Peas; (2) small dented cans Apricots, use by 2009 Campbell tomato soup, use by Oct 2003 Jar of cheese spread, best by 07/01/2006 1 rusted can of Pumpkin, use by Apr 08 1 dented 7.5 ounce can of Chicken & Dumplings, expired 2007 1 dented can of Beef Pepper La Choy, use by 12/09/2006 1 rusted can of Homestyle Chicken soup with rodent-like debris clinging to can These items were removed from the shelves by the surveyor. The ALF owner stated she would 24 make sure these items were discarded. 157. That on 12/28/2010 at approximately 10:40 AM CST the plastic bin used to store dry ) food goods was checked for content, expiration dates and package integrity in the company of the ALF owner. 158. That the owner states they keep the dry good in the plastic bin to "keep the rats from getting to it", 159. That the plastic bin contained: . (2) boxes of Corn Flakes, exp. 12/20 ° 1 box of Granola Chew Dips, exp 08/2009 . 1 box of opened powdered milk, exp. 08/01/2008 ° open box of lasagna noodles with visible soiling/dirt and debris to outside package . 1 damp box of open Pasta salad, The expired items were removed from the bin by the surveyor. The ALF owner stated she would make sure these items were discarded. 160. That an interview was conducted with the ALF owner on 12/28/2010 who said that the staff was responsible for checking the pantry and food bin for expired items. 161. That on 12/29/2010 at approximately 07:20 AM CST, 15 cans of expired vegetables were observed to be back on the pantry shelf. 162. That on 12/29/2010 at approximately 07:30 AM CST, per the ALF Assistant . Administrator, he did not know how these expired items got back on the shelf. 163. That a review of the furnished monthly expense accounting revealed the ALF indicated they spent "$3,500.00" on food monthly, however a review of the ALF food storage did not support this listed expenditure. 25 ae Saas 164. That the same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 2011 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), Fla. Stat. (2010). COUNT XI (Tag 41005) 165. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 166. That pursuant to Florida law, pursuant to Section 429.27, FS., residents shall be given | the option of using their own belongings as space permits, When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. Aclean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress a comfortable height to ensure easy access by the resident; 2. A closet or wardrobe space for hanging clothes; 3. A dresser, chest or other furniture designed for storage of personal effects; 4. A table, bedside lamp or floor lamp, and waste basket; and . 5. Acomfortable chair, if requested. Fla. Admin. Code R. 58A-5.023(2)(b) 167. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 168. That based on observation the facility failed to ensure all furniture and furnishings were in good repair. 26 169. Thata tour of the facility was conducted on 11/9/2010 at approximately 8:45AM. The following items were observed during the tour: 1. Room #3 contained a brown dresser with 5 drawers with exposed particle board, 2. The restroom near the dining area contained a sink with exposed particle board., 3. 1 green chair in the television room with ripped skirting. 170. That Class “III” 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class IT violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class I violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. §408.813(2)(c), Florida Statutes (2010) 171. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 172, That on December 29, 2010, the Agency conducted a follow-up to the biennial licensure | survey of the Respondent facility. 173. That based on observation it was determined the ALF failed to ensure the furniture was in good repair. 174. That on 12/28-29/2010 a follow up survey was conducted and the following was observed: 1. Room #3 two dressers with exposed particle board and a broken handle 2. Green chair in living room with torn skirt 175. That the same constitutes an uncorrected Class IIf deficiency as defined in Florida Statute 27 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 2011 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), Fla. Stat. (2010). | COUNT XII (Tag A619) 176. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth _ herein. 177. That pursuant to Florida law, centrally stored medications must be: 2. Located in an area free of dampness and abnormal temperature, except that a medication requiring refrigeration ' shall be refrigerated. Refrigerated medications shall be secured by being kept in a locked container within the refrigerator, by keeping the refrigerator locked, or by keeping the area in which refrigerator is located locked. Fla. Admin. Code R. 58A-5.0185(6)(b)2 178. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 179. That based on observation the facility failed to ensure centrally stored medications were kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times and failed to ensure refrigerated medications were kept in a locked container within the refrigerator. 180. That an observation on 11/9/2010 at approximately 9:30AM revealed the door of the central storage closet for medications open and unattended for approximately 3 minutes. 181. During a tour of the kitchen on 11/9/2010 at approximately 9:00-9:30AM the refrigerator contained several vials of Humulin 70/30 insulin and Risperdal injections. The medications were not in a locked container and the refrigerator was not locked. 28 182. That Class “III” 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. Ifa class II] violation is corrected within. the time specified, a fine may not be imposed. §408.813(2)(c), Florida Statutes (201 0) 183, That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 184. That on December 29, 2010, the Agency conducted a follow-up to the biennial Licensure survey of the Respondent facility. 185. That based on observation the facility failed to ensure that centrally stored medications were kept in a locked room at all times. 186. During the initial tour of the ALF on 12/28/2010 at approximately 09:15 CST, the medication room door was observed to be wide open. There were 4 residents sitting in the adjacent room watching television. An employee was at the side door sweeping. Inside the room there were medication bottles laying out on the desk, multiple bags containing patient medications and insulin syringes. 187. ‘The ALF kitchen was also noted open and medications were stored in the refrigerator inside a black metal box noted to-be locked, however the key to the box was noted on a nail next to the refrigerator. 188. That the same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 2011 189. That on February 2, 2011, the Agency conducted a second follow-up to the biennial 29 wegen” licensure survey of the Respondent facility. 190. That based on observation the facility failed to ensure that centrally stored medications were kept in a locked room at all times. 191. . During the initial tour of the ALF on 02/02/2011 at approximately 09:30 AM CST, the medication room door was observed to be unlocked. There was a bag of medication with several medication cards/packs inside sitting on the shelf, There was no one in sight. This was verified by an additional surveyor, 192. That the same constitutes a twice uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of March 2, 2011. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Fla. Stat. (2010), COUNT XIII (Tag A625 193, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 194. That pursuant to Florida law, medications which have been abandoned or which have expired must be disposed of within 30 days of being determined abandoned or expired and disposition shall be documented in the resident’s record. The medication may be taken to a pharmacist for disposal or may be destroyed by the administrator or designee with one witness, Fla. Admin. Code R. 58A-5.0185(6)(e) 195. That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 30 196. ' Thatbased on observation and interview the facility failed to ensure medications Which have expired were disposed of within 30 days of being determined expired. 197. During a tour of the kitchen on 11/9/2010 the refrigerator contained a sealed box. of Risperdal injections with an expiration date of 2/2010, 198. Thatthe assistant administrator confirmed the medication was expired. 199, That Class “III” 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class I] violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class Ill violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within | the time specified, a fine may not be imposed. $408.813(2)(c), Florida Statutes (2010) 200. That the Agency provided Respondent with a mandatory ‘correction date of December 9, 2010. | 201. Thaton December 29, 2010, the Agency conducted a follow-up to the biennial licensure survey of the Respondent facility. 202. That based on observation and interview the facility failed to ensure medications which have been abandoned were disposed of within 30 days of being determined abandoned. 203. During an observation on 12/28/2010 at approximately 11:40 CST, the refrigerator contained a locked medication box with a box/bottle of Haloperidol injectable labeled with a resident that had been discharged back in August 2010. 204. That an interviewed was conducted, at the time of the observation, with the Administrator and Assistant Administrator. The Assistant Administrator stated that the resident left in August and that they "simply forgot" to send the medication back to the pharmacist. 31 one” 205. Thatthe same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429,19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 201] 206. That on February 2, 2011, the Agency conducted a second follow-up to the biennial licensure survey of the Respondent facility. . 207, That based on observation and interview the facility failed to ensure medications which | have been expired were disposed of within 30 days of being determined expired. 208. During an observation of the medication storage room in the presence of the administtator on 2/1/2011 at approximately 10:40AM, the surveyor observed 1 bottle of Flaticasone Propionate nasal spray S0meg expired on 5/2010 sitting on the letter holder. 209. That the administrator confirmed the medication was expired and stated she thought they had returned all expired medications to the pharmacy. 210, That the same constitutes a twice uncorrected Class III deficiency as defined in Florida Statute 429.1906) (2010) and the Agency provided a mandatory correction date of March 2, 201, . WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Fla. Stat. (2010). COUNT XIV (Tag A801) 211. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 212. That pursuant to Florida law, when food service is provided by the facility, the administrator or a person designated in writing by the administrator shall: (b) Perform his/her duties in a safe and sanitary manner. Fla. Admin. Code R. 58A-5.020(1)(b) 32 213. . That on November 9, 2010, the Agency conducted a biennial licensure survey of the Respondent facility. 214. That based on observation and interview it was determined the ALF failed to ensure sanitary food storage and preparation. 215. That on 11/9/2010 at 9:00 AM CST several packages of frozen Pork chops were observed _ on the kitchen counter thawing. The pork chops were again observed on the counter at 10:30 AM CST. 216. That on 11/9/2010 at 11:50 AM CST the central food pantry in the kitchen was observed, The pantry contained the ALF's standard food supply and emergency food storage. There were several bags/boxes of rice, bread crumbs, sugar, powdered milk and crackers that had areas that appeared to be chewed by rodents. 217. That the shelves contain rodent-like droppings and spilled food particles. The cans appeared dusty and some were bent: 218. An interview with the kitchen staff at this observation was conducted and she stated she was not aware any mice or rodents had been in the pantry. 219. That Class “III” 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class ITI violation. A citation for a class IH violation must specify the time within. which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. §408.813(2)(c), Florida Statutes (2010) 220. That the Agency provided Respondent with a mandatory correction date of December 9, 2010. 33 221. Thaton December 29, 2010, the Agency conducted a follow-up to the biennial Licensure survey of the Respondent facility. 222. Thatbased on observation and interview it was determined the ALF failed to ensure sanitary food storage and preparation. 223. Thaton 12/28/2010 at approximately.10:15 AM CST the central pantry between the kitchen and laundry room was observed along with the owner of the ALF. The pantry contained the ALF's standard food supply and water stored in reused plastic containers. The shelves contained rodent-like droppings throughout. 224, That the canned items were checked for expired dates and package integrity and revealed: ¢ Dented can of sliced beets, use by 11/30/2007 ¢ Picante sauce, use by 01/28/10 e 1 can of beans with chewed/shredded label suggesting rodent-like chew marks ¢ dented can of Kidney Beans ¢ Ranch-style black beans, use by 07/31/2008 * opened undated bottle of BBQ sauce with instructions to refrigerate after opening ¢ dented can of black beans, use by 03/2010 « (4) 1 qt size Cheddar Cheese soup, use by 03/22/2007 ¢ 1 can of Jellied Cranberry sauce, use by 09/21/2006 « (4) 1qt cartons of Roast Red Pepper Tomato Soup, use by 1 April 2007 . ¢ 1 can of cream corn rusted and shredded label e Dented can cranberry sauce ¢ 1 can rusted ‘corroded Great Northern Beans e 1 can Chick Peas, use by 07/26/2008, an additional rusted can of Chick Peas; ¢ (2) small dented cans Apricots, use by 2009 34 ae « Campbell tomato soup, use by Oct 2003 « Jar of cheese spread, best by 07/01/2006 ¢ 1 rusted can of Pumpkin, use by Apr 08 ¢ 1 dented 7.5 ounce can of Chicken & Dumplings, expired 2007 ¢ 1 dented can of Beef Pepper La Choy, use by 12/09/2006 * 1 rusted can of Homestyle Chicken soup with rodent-like debris clinging to can These items were removed from the shelves by the surveyor. The ALF owner stated she would make sure these items were discarded. . 225. Thaton 12/28/2010 at approximately 10:40 AM CST the plastic bin used to store dry food goods was checked for content, expiration dates and package integrity in the company of the ALF owner. 226. That the owner states they keep the dry good in the plastic bin to "keep the rats from getting to it". 227, That the plastic bin contained: ° (2) boxes of Corn Flakes, exp. 12/20 ° 1 box of Granola Chew Dips, exp 08/2009 ° 1 box of opened powdered milk, exp. 08/01/2008 ° open box of lasagna noodles with visible soiling/dirt and debris to outside package e 1 damp box of open Pasta salad. The expired items were removed from the bin by the surveyor. The ALF owner stated she would make sure these items were discarded. 228. That an interview was conducted with the ALF owner on 12/28/2010 who said that the staff was responsible for checking the pantry and food bin for expired items. 229. That on 12/29/2010 at approximately 07:20 AM CST, 15 cans of expired vegetables were 35 observed to be back on the pantry shelf. 230. Thaton 12/29/2010 at approximately 07:30 AM CST, per the ALF Assistant Administrator, he did not know how these expired items got back on the shelf. 231, Thata review of the furnished monthly expense accounting revealed the ALF indicated they spent ''$3,500.00" on food monthly, however a review of the ALF food storage did not support this listed expenditure. 233, Thatthe same constitutes an uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of January 29, 2011. 234. That on February. 2, 2011, the Agency conducted a second follow-up to the biennial licensure survey of the Respondent facility. 235, That based on observation and interview it was determined the ALF failed to ensure sanitary food storage and preparation. 236. That on 02/02/2011 at approximately 09:45 AM CST the central pantry between the kitchen and laundry room and the refrigerator were observed along with the owner and staff member of the ALF. 237, That the pantry contained the ALF's standard food supply and water stored in reused plastic containers. The canned items and refrigerated items were checked for expired dates and package integrity and revealed: . PANTRY: e Unopened bottle of Kraft Tartar Sauce - best use by date of June 04, 2010. e Can El Paso refried beans - can dented and corroded ¢ Jar of Hatch Picante Sauce - best used by date of 01/28/2010 REFRIGERATOR: 36 ‘whys ¢ Plastic squeeze bottle of Mayonnaise Hot and Spicy - best use by date of August 31, 2005. The staff member of the ALF said she thought this was something they had mixed up and put in that bottle. ¢ Jar of Olives - best use by date of 2008 ¢ Can of Glucerna, 8 ounces - best use by date of May 1, 2010 238. That the same constitutes a twice uncorrected Class III deficiency as defined in Florida Statute 429.19(2)(c) (2010) and the Agency provided a mandatory correction date of March 2, 2011. . | WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Fla. Stat. (2010). COUNT XV 239. The Agency re-alleges and incorporates Count I through Count XIV of this Administrative Complaint as fully set forth herein. 240, That pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in chapter 120 against a licensee for a violation of any provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under s. 408.809, or for the actions of any facility employee: (e) A citation of any of the following deficiencies as specified in s. 429.19: 3. Five or more cited class III deficiencies that have been cited on a single survey and have not been corrected within the times specified. §429.14(1)(e)3., Florida Statutes (2010). 37 241. Thatunder Florida law, the Agency may deny or revoke the license of an ALF operator based upon the facility’s (6) intentional or negligent act materially affecting the health or safety of a client of the provider, (c) a violation of this part, authorizing statutes, or applicable rules and (d) a demonstrated pattern of deficient performance.§408.815(1) Florida Statutes (2010). 242, That Respondent has violated the minimum requirements of law of Chapters 408, Part II, 429, Part I, and Chapter 58A-5, Florida Administrative Code as described with particularity within this complaint. 243. . That Respondent has a duty to maintain its operations in accord with the minimum requirements of law and to provide care and services at mandated minimum standards. 244. That the above reflect grounds for which the Agency may revoke Respondent’s licensure to operate an assisted living facility in the State of Florida. 245. .That based thereon, individually and collectively, the Agency seeks the revocation of the Respondent’s licensure. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§408.812(5) and 429.14, 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 Counts I through XV; (B) Recommend administrative fines against Respondent in the amount of $12,500; (C) Revoke Respondent’s license # 9555 to operate an assisted living facility; (D) Assess attorney’s fees and costs; and (E) Grant all other general and equitable relief allowed by law. 38 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action ate 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. If you want 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 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, Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 412-3630 CERTIFICATE OF SERVICE T HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7009 0960 0000 3709 5935 to Judy E. Brown, Administrator, Brown’s Harbor House, 1619 Monroe Sheffield Road, Chipley, Florida 32428 and via email to Dawn Pompey Whitehurst, Esq., Knowles & Randolph, P.A., 3065 Highland Oaks Terrace, Tallahassee, Florida 32301 on June 7, 2011. D. Carlton Enfingep I Copy furnished to: ( Donah Heiberg, FOM 39 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: MARGIE BROWN, d/b/a BROWN’S HARBOR HOUSE, CASENO — 2011005989 . 2011005987 2011005983 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 Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine ot Administrative Complaint. If your Election of Rights with your selected 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 right 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 according to 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: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY | OF THESE 3 OPTIONS OPTION ONE (1). I admit to the allegations of facts 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. | 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 to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, 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)____—S— I dispute the allegations of fact contained in the Notice of Intent te 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 Administ,../ve Hearings under Section 120.57(1), lorida 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, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. . 2. The file nurnber of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. A. 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: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: : Name Title Address: Street and number City _ Zip Code Telephone No. Fax No. Email(optional) I hereby 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 licensee referred to above. Signed: Date: Print Name: ; Title: Late fee/fine/AC Postage | $ Cantified Feo Return Receip Fee Postmark (Endorsement Requires) Here aooa 3905 ses Restricted Deliye, Fe yh (Endorsoment Reqelners, a Gg Tolal Postage & Fees $ Cl Agent i © Addresses °O D. Is delivery address different from item 1? Cl Yes : ITYES, enter detivery address below: [No ‘ Or on the front If Space permits, 1. Articte Addressed to; Oud . Bren \ Fm On, Brags Nene Besa (& rm Montane Ste Rie agy ; Copley FRAY ay ©) Certified Mall © Express Mall C1 Registered C7 Return Recej Oltnsured Mai = C.0.D, 4, Restrloted Delivery? (Extra Fee) “7. °U04 OFK0 O000 3704 $435 PS Form 3811, February 2004 Domestic Return. Receipt. - ipt for Merchandise 102595-02-M-1540 |

Docket for Case No: 11-003355