STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR “ow HEALTH CARE ADMINISTRATION, : Petitioner,- ANDRADA- SUNSHINE..CORPORATION d/b/a GOOD SAMARITAN RETIREMENT HOME, Respondent. / ADMINISTRATIVE COMPLAINT COMES Now the Agency For Health Care Administration (the ‘Agency”) and files this administrative complaint against ' Andrada Sunshine Corporation d/b/a Good Samaritan Retirement Home, (“Respondent” or “Respondent Facility”), pursuant to §§ + 120.569, and 120.57, Fla. Stat., and alleges: : NATURE OF THE ACTION vale This is an action to revoke the license of Respondent, to impose an administrative fine in the amount of six thousand dollars ($6,000.00) and for such other relief as this tribunal may determine, based upon two uncorrected class III deficiencies and five class II deficiencies, pursuant to Chapters 408, Part II, and 429, Part I, Fla. Stat. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and 429.07, and Chapters 408, Part II, and 429, Page 1 of 43 Filed March 28, 2012 3:29 PM Division of Administrative Hearings Part I, Florida Statutes. 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207, PARTIES enforces all applicable Florida statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and - Chaptér 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4, Respondent operates a 65-bed assisted living facility located at 507 S.E. ist Avenue, Williston, Florida 32696, and is licensed as an assisted living facility, license number 25. 5. At all times material to this complaint, Respondent was licensed by the Agency and was required to comply with all applicable rules and statutes. , _ COUNT I A0152 6. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 7. Rule 58A-5,023(3), Florida Administrative Code, | provides: (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1) (a), F.S.% and 2, Must be maintained free of hazards; and 3. Must ensure that all existing architectural, mechanical, electrical and structural systems and appurtenances are maintained in good working order. (o) Pursuant to Section 429,27, F.S., residents shall Page 2 of 43 we 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. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of 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. A comfortable chair, if requested. (c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency. : (d). Residents who use portable bedside commodes must be provided with privacy during use. (e) Facilities must make available linens and personal laundry services for residents who require such services. Linens provided by a facility shall be free of tears, stains and not be threadbare. 8. Section 429.28, Florida Statutes, provides: 429,28 Resident bill of rights.— (1) No resident of a facility shall be deprived of any 4 : 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. 9, On July 6 and 7, 2011, the Agency conducted a biennial licensure survey of the Respondent. 10. Based on the Agency’s surveyor’s observations, interviews, and review of Respondent's records, the Agency determined that the Respondent failed to provide a decent and Page 3 of 43 safe living environment, free from hazards and in good working order. 1. During the Agency’s surveyor’s initial tour of the Respondent’s facility on ly 6 1 : concluding at 10:30 PM, the following issues were identified: - Room A-2: the bathroom shower head was almost completely covered with a crusty rust-like substance. Room# A-5 The bathroom had numerous stained ceiling tiles surrounding the sprinkler head. There was also a 5 inch by 6 inch hole in the wall by the bathroom door, and a small ‘ hole was found beside the light switch, also in the bathroom. Room #A~7 was found to have a significant amount of ceiling paint peeling in the bathroom. Room # A~8 had a ceiling vent cover that was broken. Room #A~9 was found to have a ceiling skylight that had significant peeling paint. Room # B-2 had what appeared to be rust-type staining on the ceiling of the bedroom area. Rooms # B-3 and B~6 had numerous areas of the bedroom walls that were missing paint. Room# B~12 had peeling wallpaper beside the window, ceiling molding was very loose, bathroom tiles were broken, and the bedroom blinds were bent and damaged to the point the Page 4 of 43 eed resident was unable to have complete privacy from the window that opens to the outside of the facility. Room #B-14 had significant water stains on the ceiling Room # B-15 was found to have hinges on the outside of the door to the room which were not solidly connected to hold the door in place. Room B-17: the bathroom toilet seat was found to be loose, the shower head was crusted with a rusty-type substance, the sink faucet was dirty and had areas that appeared to be a rusty type substance, there was no drain cover in the shower, and the shower step area was missing multiple | tiles. 12. The Agency’s surveyor conducted an interview with the 4 . Respondent’s owner on July 6, 2011 at 2:45 PM. The Agency's surveyor was told that the owner checks each resident's room approximately three times weekly to check for environmental issues. The Agency’s surveyor was also told by the Respondent’s owner that the owner will repair anything that the owner identifies as needing repair, and that the owner reviews the maintenance log to follow up on entries made by the residents or staff. Page 5 of 43 we 13. The Agency’s surveyor’s review of Respondent's documents failed to reveal a maintenance plan as of July 6, 2011, at 3:00 PM. 14. The Agency determined that Respondent’s deficient practice of failing to provide a decent and safe living environment, free from hazards and in good working order was 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 the residents and cited Respondent for a State Class III deficiency. ) 15. The Agency provided Respondent with a mandatory correction date of August 7, 2011. . 16, On August 16, 2011, the Agency conducted:a revisit survey at the Respondent facility. 17. Based on the Agency’s surveyor’s observations and interviews the Respondent still failed to provide a decent and safe living environment, free from hazards and in good working order. 18. During the Agency! s surveyor’s tour of the facility on August 16, 2011, starting at 8:45 AM and ending at 9:45 AM, the following issues were identified: Room #B-2, there was a 4" X 4" hole in the tile over the sink in the bathroom. Page 6 of 43 Room #B~12, the molding next to the ceiling was loose. Room #B-17, the toilet seat was loose. The control handle for changing the water. flow from tub to shower was loose eee bce surface of the tub. "Cc" building, the air conditioner vent located in the lobby of the building had a large build-up of dirt and dust, and it appeared that something was growing on it. "D" building, a hole of approximately 3" X 4" was found in the hallway wall located approximately halfway down the hall, next to the emergency exit. 19. In an interview with Respondent's employees #1, #2 and #7 on August 16, 2011, at 12:40 PM, the Agency’s surveyor was told that the employees were not aware of the listed conditions in room B=-2, "C" building or "D" building. Employee #7 confirmed the condition of room # B-17, 20. The Agency determined that Respondent’s deficient practice of failing to provide a decent and safe living environment, free from hazards and in good working order was 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 the residents and cited Respondent for a State Class III deficiency. Page 7 of 43 21. The Agency provided Respondent with a mandatory correction date of September 16, 2011. ' 22, The Agency determined that the above-described Agency's July 6 and 7, 2011, survey, was uncorrected at the time of the Agency’s August 16, 2011, survey for purposes of 8§ 408.813 and 429,19, Florida Statutes. 23. On September 22, 2011, the Agency conducted a ‘second revisit survey at the Respondent facility. 24, Based on the Agency’s surveyor’s observations and interviews the Respondent still failed to provide a decent and safe living environment, free from hazards and in good working order. 25. During the Agency’s surveyor’s tour of Respondent's -| facility on 9/22/11 starting at 9:04 AM and ending at 1:50 PM | the following issues were identified: Loose handrail noted in hallway by dining room across from the kitchen, Room B-16 Closet door broken. "D" building, loose handrail noted in main hallway. Room D-6, door return arm was broken. Loose handrail noted next to exit door in the middle of the hallway - "D" building. Loose handrail noted at the end of the hallway Page 8 of 43 ~~ "D" building Fire Extinguisher missing from its container box located in the living room of "D" building and fire alarm pull station noted in pulled position next to empty box ~ locked unit. D-2, Baseboards noted to be dirty. Columns X4 located on the front porch near the front door are noted to have soft/spongy wood. All columns appear to be rotting at their bases. | mp" building dining room noted to have approximately 3" x 3" tile damage in the middle of the floor. There are 3 of 4 alarm pull stations noted in pulled (down) position, 4th station does not contain small glass bar Bave located by the fire place of the main building was noted to have rotting wood. Room # C-1, air conditioner vent was observed to be dirty with growth. "c" pbuilding, rain gutter located on both front and back of building are missing pieces and are separating from the building. The handicap shower located in the back of "B" building had no drain cover, just rough edges of tile; the base of the shower was corroded. ; The exterior walls of the TV. room in the front of "B" building (located across from the front door) are cracked with approximately 1/2" wide gap, and the window sill was also cracked with approximately 1/2" gap. Air vents and air returns were noted to be dirty. The electrical plugs and fire sprinklers were observed to be dirty in the kitchen. The emergency light tagged #EL-A5 located in the front lobby of the main building did not come on when tested. "D" building fire extinguisher needed to be replaced. Page 9 of 43 raed me’ 26. In an interview conducted on 9/22/2011 at 11:08 AM with Resident #5, the Agency’s surveyor was told that members of Respondent’s staff have been notified on numerous occasions of —+________the_condition of the vent in Room C=i and at times things blow off of the vent and on to the Resident’s chair located below it. i 27. In an interview with Respondent’s employees #1 and #2 on 9/22/2011, during the Agency’s surveyor’s tour of the Respondent, the Agency’s surveyor was told that thé employees were not aware of the conditions listed in paragraph 25, above. | "28, The Agency determined that Respondent's deficient practice of failing to provide a decent and safe living environment, free from hazards and in good working order was related to the related to the operation and maintenance of a provider or to the care of clients which the agency determines 4 indirectly or potentially threaten the physical or emotional . ‘health, safety, or security of clients the residents and cited Respondent for a State Class III deficiency. 29, The 30. The Agency determined that the above-described deficient practice by Respondent, identified at the time of the Agency’s July 6 and 7, 2011, survey and identified again at the Agency’s survey of August 16, 2011, was still uncorrected at the time of the Agency’s September 22, 2011, second revisit survey for purposes of §§ 408.815, 408.813 and 429.19, Florida Page 10 of 43 we a Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted uncorrected class III violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT II A0160 31. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 32. Rule 58A~5.024(1), Florida Administrative Code, provides: The facility shall maintain the following written records in a form, place and system ordinarily employed in good business practice and accessible to Department of Elder Affairs and Agency staff. ! (1) FACILITY RECORDS. Facility records shall include: } (a) The facility’s license which shall be displayed in : a conspicuous and public place within the facility. (b) An up-to-date admission and discharge log listing the names of all residents and.each resident’s: 1. Date of admission, the place from which the resident was admitted, and if applicable, a notation the resident was admitted with a stage 2 pressure sore; and 2. Date of discharge, the reason for discharge, and the identification of the facility to which the resident is discharged or home address, or if the person is deceased, the date of death. Readmission of a resident to the facility after discharge requires a new entry. Discharge of a resident is not required if the facility is holding a bed for a resident who is out of the ; facility but intends to return pursuant to Rule 58A~ 5.025, F.A.C. . . Page Li of 43 (k) A grievance procedure for receiving and responding to resident complaints and recommendations as described in Rule 58A-5.0182, F.A.C. (4) RECORD INSPECTION. (a) All records required by this rule chapter shall be i ni i i of the agency, the department, the district long-term care ombudsman council, and the advocacy center for persons with disabilities. 33. Rule 58A-5.0182(6), Florida Administrative Code, provides: (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a)... (b) In accordance with Section 429,28, F.S., the facility shall have a written grievance procedure for receiving and responding to resident complaints, and for residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. 34, . On July 6 and 7, 2011, the Agency conducted a biennial licensure survey of the Respondent. 35. Based on the Agency’s surveyor’s review of Respondent’s records and interviews, the Agency determined that Respondent failed to maintain current and up-to-date facility records. . 36. The Agency’ s surveyor’s review of the Respondent's admission and discharge log on July 6, 2011, revealed that six (6) resident entries were incomplete — for all six discharged residents the log had no discharge date or place of discharge. Page 12 of 43 Respondent's admission and discharge log indicated that the following were still residents: Resident #1 with an admission date of 12/21/10, Resident #2 with an admission date of 5/21/10, i Gate of 11/21/08, Resident #4 with an admission date of 1/26/01, Resident #5 with an admission date of 9/6/1999, and Resident #6 with an admission date of 6/23/1994 37. In an interview with the Respondent's Administrator on July 6, 2011, at 10:15 AM, the Agency’s surveyor was told that the administrator was not aware of the missing information on the admission and discharge log. 38. The Agency determined that this deficient practice of failing to ensure that the admission and discharge log was up- to-date was a failure to maintain current and up-to-date facility records related to the operation and maintenance of a provider or to the care of clients which the agency determines i indirectly or potentially threaten the physical or emotional health, safety, or security of the residents and cited Respondent for a State Class III deficiency. . 39, The Agency provided Respondent with a mandatory _correction date of August 7, 2011. 40. On August 16, 2011, the Agency conducted a revisit survey at the Respondent facility. 41. Based on the Agency’s surveyor’s review of Respondent’s records and interview, the Agency determined that Page 13 of 43 ew ne Respondent still failed to maintain an up-to-date admission and discharge log. 42. The Agency’s surveyor’s review of the Respondent's was no entry for Resident #1. 43. In an interview with Respondent’s employees #1 and #2. on August 16, 2011, at 11:05 AM, the Agency’s surveyor was told that Resident #1 was admitted to Respondent's facility on October 20, 2010. Employee #2 found the admission information in Resident #1's chart. Neither employee #1 nor employee #2 was aware that Respondent’s admission and discharge log lacked an entry for Resident #1. Oe 44, The Agency determined that this deficient practice of failing to maintain a current and up-to-date facility records was 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 the residents and cited Respondent for a State ‘Class III deficiency. 45, The Agency provided Respondent with a mandatory correction date of September 16, 2011. 46. The Agency determined that the above-described deficient practice by Respondent, identified at the time of the Agency’s July 6 and 7, 2011, survey, was uncorrected at the time Page 14 of 43 nn of the Agency’s August 16, 2011, survey, for purposes of §§ 408.813 and 429.19, Florida Statutes. 47. On September 22, 2011, the Agency conducted a second = yevisit sUevesy at the Re £ S144 “48. Based on the Agency's surveyor’s observations and interviews the Respondent still failed to maintain current and up-to-date facility records, 49. Upon the Agency’s surveyor’s inguiry as to Respondent’s ability to demonstrate that it had implemented its written grievance procedure for receiving and responding to _ resident complaints, and for residents to recommend changes to facility policies and procedures, Respondent's personnel were unable to produce a complaint log for review. 50. In an interview with Respondent’s employees #1 and #2 on 9/22/11 at 12:25 PM, the Agency’s surveyor was told that they were unable to locate any complaint log. 51. The Agency determined that this deficient practice of failing to maintain a current and up-to-date facility records ‘was 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 the residents and cited Respondent for a State Class III deficiency. 52. The Agency determined that the above-described Page 15 of 43 | deficient practice by Respondent, identified at the time of the Agency’s July 6 and 7, 2011, survey, and uncorrected at the Agency's survey of August 16, 2011, was still uncorrected at the —j-—hime_of_the Agency's September 22,—survey, for_purposes of $$ ___ 408,813, 408.815 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, for the above-described uncorrected class III violation, pursuant to Chapters 408, Part ‘ tI, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT III A0161 53. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. as : 54. Rule 58A-5.024(2), Florida Administrative Code, | requires: (2) STAFF RECORDS. (a) Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis, In addition, records shall contain the following, as applicable: 1. Documentation of compliance with all staff training required by Rule 58A-5,0191, F.A.C.; 2. Copies of all licenses or certifications for all staff providing services which require licensing or certification; 3. Documentation of compliance with level 1 background screening for all staff subject to screening. requirements as required under Rule 58A-5.019, F.A.C.; Page 16 of 43- de ue 4. BR copy of the job description given to each staff member pursuant to Rule 58A~-5.019, F.A.C., for facilities with a licensed capacity of seventeen (17) or more residents; and 5. Documentation of facility direct care staff and administrator participation in resident elopement (b) The facility shall not be required to maintain personnel records for staff provided by a licensed staffing agency or staff employed by a business entity contracting to provide direct or indirect services to residents and the facility. However, the facility must maintain a copy of the contract between the facility and the staffing agency or contractor as described in Rule 58A-5.019, F.A.C, : : (c) The facility shall maintain the facility’s written work schedules and staff time sheets as required under Rule 58A-5.019, F.A.C., for the last 6 months. 55, Rule 58A-5.019(2), Florida Administrative Code, requires: (2) STAFF, (a) Newly hired staff shall have 30 days to submit statement from a health care provider, based on a examination conducted within the last six months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis. Freedom from tuberculosis must- be documented on an annual basis. A person with a positive tuberculosis test must submit. a health care provider’s statement that the person does not constitute a risk of communicating tuberculosis. Newly hired staff does not include an employee transferring from one facility to another that is under the same management or ownership, without a break in service. If any staff member is later found to have, or is suspected of having, a communicable disease, he/she shall be removed from duties until the administrator determines that such condition no longer exists. (bo) All staff shall be assigned duties consistent with his/her level of education, training, preparation, and experience. Staff providing services requiring licensing or certification must be appropriately licensed or certified. All staff shall exercise their responsibilities, consistent with their qualifications, Page 17 of 43 to observe residents, to document observations on the appropriate resident’s record, and to report the observations to the resident’s health care provider in accordance with this rule chapter. (c) All staff must comply with the training requirements of Rule 58A-5.0191, F.A.C. a business entity contracting to provide direct or indirect services to residents must be qualified for the position in accordance with this rule chapter. The contract between the facility and the staffing agency er contractor shall specifically describe the services the staffing agency or contractor will be providing to residents. (e) For facilities with a licensed capacity of 17 or more residents, the facility shall: 1. Develop a written job description for each staff position and provide a copy of the job description to each staff member; and 2. Maintain time sheets for all staff. 56, On July 6 and 7, 2011, the Agency conducted a biennial licensure survey of the Respondent. 57. Based on the Agency’s surveyor’s review of Respondent’s records and interviews, the Agency determined that the Respondent failed to have complete and adequate staff records to document that Respondent's staff met minimum requirements to work in an assisted living facility. Specifically, of the six (6) records of Respondent’s staff chosen for the Agency’s surveyor’s review, three, employees #1, #2, and #3, did not have freedom from communicable disease statements; two, employees #1 and #4, did not have tuberculosis testing; and one, employee #1, had no job description and no employment references. Page 18 of 43 a Me 58. The Agency determined that this deficient practice of failing to have complete and adequate records to show that each of Respondent’s staff members met minimum requirements for i: ki . : . 1 Li 3 £ ili la 4 I . operation and maintenance of a provider or to the care of clients which the agency determined indirectly or potentially threaten the physical or emotional health, safety, or security of the residents and cited Respondent for a State Class III deficiency. “59, The Agency provided Respondent with a mandatory correction date of August 7, 2011. 60. On August 16, 2011, the Agency conducted a revisit survey at the Respondent facility. 61. Based on the Agency’s surveyor’s review of Respondent’s records and interview, the Agency determined that Respondent still failed to have complete and adequate records that Respondent's staff met minimum qualifications to work in an assisted living facility. Specifically, of Respondent's six employees whose files were reviewed by the Agency’s surveyor two employees, employees #5 and #6, lacked freedom from communicable disease statements, and one, employee #6, lacked tuberculosis testing and employment references. 62. The Agency surveyor’s review of the records for employee #5 with a hire date of 05/09/11 failed to find Page 19 of 43 documentation from a healthcare provider stating that employee #5 was free from communicable disease. 63. The Agency's surveyor'’s review of the records for _|_______employee #6 with a hire date of 03/20/11 failed to find documentation from a healthcare provider stating that employee #6 was free from communicable disease, failed to find test references. 64, In an interview with employee #1 on 08/16/11 at 12:40 PM employee #1 stated that employee #1, was not aware of the missing documentation for communicable disease for either employee #5 or employee #6, but stated that employee #6 had a positive test for tuberculosis and was to have a chest X-ray performed. 4d 65. The Agency determined that this deficient practice of failing to have complete and adequate records to show that each of Respondent’s staff members met minimum requirements for working in an assisted living facility was related to the operation and maintenance of a provider or to the care of clients which the agency determined indirectly or potentially threaten the physical or emotional health, safety, or security of the residents and cited Respondent for a State Class III deficiency. 66. The Agency informed Respondent that the Agency had Page 20 of 43 q ab assigned a mandatory correction date of 09/16/11 to this violation, 67, The Agency determined that the above-described deficient _practice—by Respondent,—identi fied atthe timeof-the Agency’s July 6 and 7, 2011, survey, was uncorrected at the time of the Agency’s August 16, 2011, survey, for purposes of 8§ 408.813 and 429.19, Florida Statutes, ; 68. On September 22, 2011, the Agency conducted a second revisit survey at the Respondent facility. 69. Based on the Agency's surveyor’s observations and interviews the Respondent still failed to have complete and adequate records that Respondent’s staff met minimum qualifications to work in an assisted living facility. Specifically, of Respondent’s five employees whose records were reviewed three -- employees #5, #6 and #7 -- lacked communicable disease statements; one, employee #5, lacked documentation of tuberculosis testing; and employee #5 also lacked an accurate training certificate. 70. The Agency’s surveyor’s review of employee #5’s file found a hire date of 1/3/11, but failed to find documentation from a healthcare provider that employee #5 was free from communicable disease or any test results for tuberculosis ‘testing. 71. Review of employee #6’'s record found a hire date of Page 21 of 43 aa 6/6/10, but failed to find documentation from a healthcare provider that employee #6 was free from communicable disease. 72. Review of employee #7’s record found a hire date of provider stating that employee #7 was free from communicable disease. 73. The Agency’ s surveyor’s interview with employees #1 and #2 on 9/22/11 at 7:30 PM confirmed that the employees were missing proper documentation. 74, The Agency’s surveyor’s review of employee #5's record found a training certificate dated 8/26/11, for Alzheimer's training that appeared to be. altered. Further review revealed | some typed letters and the hand-written employee's name. 75. In an interview with employees #1 and #2 on 9/22/11 at 7:30 PM, employees #1 and #2 failed to have any response to the Agency's surveyor’s inguiry about employee 5’s training certificate apparently being altered. 76. On 9/26/11 at 2:43 PM, the Agency’s surveyor interviewed the Alzheimer's instructor who provided training to members of Respondent’s staff on 8/26/11. The instructor stated that she did provide training to the facility's staff on August 26, 2011. She stated that she always types each participant’ s name on the certificate, and that she never hand-writes their name. The instructor sent an electronic mail message to the Page 22 of 43 aed Agency's surveyor listing the names of all who attended the training. However, the e-mail sent by the instructor did not include employee #5's name as attending the training. have complete and adequate records that Respondent's staff met ~ minimum qualifications to work in an assisted living facility as found by the Agency’s surveyor on September 22, 2011, was a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents and cited Respondent for a State Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted = living facility in the State of Florida, for the above-described class II violation, pursuant to Chapters 408, Part II, and 429, ; Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT IV A030 78. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 79. Section 429.28, Florida Statutes, sets forth the rights held by each resident of an assisted living facility: 429,28 Resident bill of rights.— Page 23 of 43 (1) 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 ina from abuse and neglect. (bo) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. (c) Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. (ad) Unrestricted private communication, including receiving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. at a minimum. Upon request, the facility shall ‘make provisions to extend visiting hours for caregivers and out-of-town guests, and in other similar | situations. (e) Freedom to participate in and benefit from community services and activities and to achieve the highest possible level of independence, autonomy, and interaction within the community. (£) Manage his or her financial affairs unless the resident or, if applicable, the resident's representative, designee, surrogate, guardian, or attorney in fact authorizes the administrator of the facility to provide safekeeping for funds as provided ins. 429,27. (g) Share a room with his or her spouse if both are residents of the facility. (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather. (i) Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shall be imposed upon any resident. (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community. Page 24 of 43 (k) At least 45 days’. notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents, In the case of a resident who has been adjudicated mentally incapacitated, the guardian shall be given at least 45 days’ notice of a nonemergency relocation or residency ' termination. Reasons for relocation shall be set forth in writing. In order for a facility to terminate the _ residency of an individual without notice as provided herein, the facility shall show good cause in a court of competent jurisdiction. (1) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. 80. Rule 58A~-5.023, Florida Administrative Rules, specifies: (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1) (a), F.S.; and 2. Must be maintained free of hazards; and 3. Must ensure that all existing architectural, mechanical, electrical and structural systems and _appurtenances are maintained in good working order. 81. On September 22 and 23, 2011, the Agency also conducted a complaint investigation survey of the Respondent. 82. The Agency determined that Respondent violated its residents’ right to live in a safe and decent living environment Page 25 of 43 ee by not having an operative fire alarm system: 82.a. On 9/22/2011 at 9:47 AM, the Agency’s surveyor observed that in the secure memory unit the fire alarm pull extinguisher box. However, the fire alarm was not sounding. Further observation on this date at 10:39 AM revealed 3 of the 4 alarm pull stations in Respondent’ s facility were pulled down, without the alarm sounding off. 82.b. In an interview with the Certified Building Official and Certified Fire~Safety Inspector on 9/22/2011 at 2:05 PM, the Agency’s surveyor was informed that the pull stations and alarm was not in the condition observed by the Agency’s surveyor, when the Respondent's facility was inspected on 01/06/2011. The Agency's surveyor was = told that the pull stations needed to be repaired. 82.c. In an interview on 9/22/2011 at 2:10 PM with a member from the city’s Fire Department, the Agency’s surveyor was told that the member of the Fire Department was unable to locate the Respondent’s facility's alarm box, and no one at the facility was able to take him to it. The Agency’s surveyor was also told by the official of the Fire Department that the official had spoken to the sprinkler system company and was informed that the sprinkler system was working and in order, and that the alarm system is Page 26 of 43 separate from the sprinkler system. 83. The Agency determined that Respondent also violated its residents’ right to be treated with consideration and need: 83.a. ‘on 9/22/2011 at 10:20 AM, the Agency’s surveyor observed employee #5’s interaction with residents. “the employee was unable to meet the needs of the residents who were requesting assistance. Employee #5 appeared to speak no English, and Respondent’s residents only speak English. When the Agency’s surveyor interviewed employee #5, the employee was unable to answer basic questions about his role or tasks in the facility. 83.b. During observation and interview in the dining area of D building on 9/22/2011 at 5:00 PM, employees #15 and #16 were observed standing over Residents #25 and #26, spoon-feeding them. 83.c. During observation in the main dining room at 5:45, employee #17 was observed standing over Resident #24 at the table, spoon- feeding her. 84. The Agency determined that the violations of residents’ rights set forth in paragraphs 82 and 83 each separately are conditions or occurrences related to the operation and maintenance of a provider or to the care of Page 27 of 43 residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be class II —+_____—__vielations for the purposes of sections 409,813, 408.815, 42014 and 429.19, Florida statutes. WHEREFORE , the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violations, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT V_A053 ; : 85. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 86. On September 22 and 23, 2011, the Agency conducted a complaint investigation survey of the Respondent. 87. Section 429.256, Florida Statutes, requires: (2) Residents who are capable of self-administering their own medications without assistance shall be encouraged and allowed to do so. However, an unlicensed person may, consistent with a dispensed prescription’s label or the package directions of an over-the-counter medication, assist a resident whose condition is medically stable with the self-administration of routine, regularly scheduled medications that are intended to be self-administered. Assistance with self- medication by an unlicensed person may occur only upon a documented request by, and the written informed consent of, a resident or the resident’s surrogate, guardian, or attorney in fact. For the purposes of this Page 28 of 43 Ne section, self-administered medications include both legend and over-the-counter oral dosage forms, topical dosage forms and topical ophthalmic, otic, and nasal dosage forms including solutions, suspensions, sprays, _ and inhalers. (3) Assistance with self-administration of madication (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident. (b) In the presence of the resident, reading the label, opening the container, removing a prescribed amount of medication from'the container, and closing the container, : (c) Placing an oral dosage in the resident’s hand or placing the dosage in another container and helping the resident by lifting the container to his or her mouth, (d) Applying topical medications. (e) Returning the medication container to proper storage. (£) Keeping a record of when a resident receives assistance with self-administration under this section. (4) Assistance with self-administration does not include: (a) Mixing, compounding, converting, or calculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed. (b) The preparation of syringes for injection or the administration of medications by any injectable route. (c) Administration of medications through intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube inserted in a cavity of the body. : (e) Administration of parenteral preparations. (£) Irrigations or debriding agents used in the treatment of a skin condition. (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be given “as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and at the request of a competent resident. -(i) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration Page 29 of 43 ew Me requires judgment or discretion on the part of the unlicensed person. _ 88. Rule 58A~5.0182, Florida Administrative Code, provides: (5) NURSING SERVICES. (a) Pursuant to Section 429.255, F.S., the facility may employ or contract with a nurse to: : ‘ 1. Take or supervise the taking of vital signs; -2, Manage pill-organizers and administer medications as described under Rule 58A-5.0185, F.A.C.;7 3. Give prepackaged enemas pursuant to a physician’s order; and 4. Maintain nursing progress notes. (b) Pursuant to Section 464,022, F.S., the nursing services listed in paragraph (a) may also be delivered in the facility by family members or friends of the resident provided the family member or friend does not receive compensation for such services. 89. Rule 58A-5.0185, Florida Administrative Code, requires: (4) MEDICATION ADMINISTRATION. (a) For facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a’health care provider's order or prescription label. (b) Unusual reactions or a significant change in the resident's health or behavior shall be documented in the resident’s. record and reported immediately to the resident's health care provider. The contact with the health care provider shall also be documented in the resident's record. (c) Medication administration includes the conducting of any examination or testing such as blood glucose testing or other procedure necessary for the proper administration of medication that the resident cannot conduct himself and that can be performed by licensed _ staff. 90. Based on the Agency’s surveyor’s observations, reviews of Respondent's records, and interviews, the Agency determined Page 30 of 43 that the Respondent failed to have licensed personnel provide administration of injectable medications for 2 of 16 residents, Residents #4 and #14. 91, On 9/22/2011 at 12:00 PM, at 1:00 PM and at 1:30 pM, the Agency’s surveyor observed that Respondent’s unlicensed medication technicians were preparing to administer insulin to residents who were incapable of self-administering the injections. 92. The Agency’s surveyor’s review of the medical records for Residents #4 and #14, showed a failure to document administration of insulin, including dates and times of insulin injections for the two residents. 93. On 9/22/2011 at 2:00 PM, the Agency’s surveyor observed the owner of Respondent, who is a Registered Nurse (RN). The owner did not know where the insulin administered to Respondent's residents was stored, but Respondent’s Administrator showed him where it was. 94. The Agency’s surveyor conducted an interview with Respondent’s Administrator on 9/22/2011 at 3:00 PM. The Administrator told the Agency’s surveyor that a terminated Assistant Administrator, who was a Certified Nursing Assistant, formerly provided the insulin injections, until 9/13/2011. The owner of the facility is a Registered Nurse (“RN”), but on September 14, 15, 16, 17, 18, 19, 20 and 21, 2011, other Page 31 of 43 —____—staff_and_medications— employees of respondent who are not licensed professionals provided the residents with their insulin shots. The Administrator admitted knowing the limitations of unlicensed 95, ‘The Agency determined that Respondent's allowing unlicensed professionals to administer injectable medications to residents is a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threatens the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT VI A054 96. The Agency re-alleges and incorporates paragraphs 1 through 5 and 87 through 89, as if fully set forth in this count. 97. Rule 58A~5.024, Florida Administrative Code, requires: Page 32 of 43 (3) RESIDENT RECORDS. Resident records shall be maintained on the premises and include: (th) For facilities which manage a pill organizer, assist with self-administration of medications or administer medications for a resident, the required 5.0185, FLAC. 98. Rule 58A-5,.0185, Florida Administrative Code, requires; (5) MEDICATION RECORDS. (a)... (bo) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusais. to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. 99. On September 22 and 23, 2011, the Agency also no conducted a complaint investigation survey of the Respondent. 100. Based on the Agency's surveyor’s review of Respondents records and interviews, the Agency determined that the facility failed to maintain medication records for 7 of 7 of Respondent's residents who receive insulin - Residents #4, #5, #7, #9, #14, #15, and #16. 101. The Agency’s surveyor’s review of the Medication Observation Records for Residents #4, #5, #7, #9, #14, #15 and Page 33 of 43 #16 failed to reveal any documentation had been done to record any insulin use. by any resident. 102, The Agency’s surveyor conducted an interview with the the Agency’s surveyor that a terminated Assistant Administrator, who was a Certified Nursing Assistant, formerly provided the insulin injections, until 9/13/2011. The owner of the facility is an RN, but on September 14, 15, 16, 17, 18, 19, 20 and 21, 2011, other employees of respondent who are not licensed professionals provided the residents with their insulin shots, The Administrator admitted knowing the limitations of unlicensed staff and medications. 103. tn an interview with Respondent’s employees #1 and #2 on 9/22/11 at 7:50 PM, the employees confirmed to the Agency's surveyor that no records had been maintained for the insulin injections. 104. The Agency determined that Respondent's failure to have and maintain a complete medication administration record for each resident receiving medications is a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threatens the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, Page 34 of 43 7 408.615, 429.14 and 429,19, Florida Statutes. ' WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT VII A081 105. The Agency re~alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 106, Rule 58A-5.024, Florida Administrative Code, requires: (2) STAFF RECORDS. (a) Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition, records shall contain the following, as applicable: 1. Documentation of compliance with all staff training required by Rule 58A-5.0191, F.A.C.; oe 107. Rule 58A-5,0191, Florida Administrative Code, requires: (9) ALZHEIMER'S DISEASE AND RELATED DISORDERS (“ADRD”) TRAINING REQUIREMENTS. Facilities which advertise that they provide special care for persons with ADRD, or. who maintain secured areas as described in Chapter 4, Section 434.4.6 of the Florida Building Code, as adopted in Rule 9N-1.001, F,.A.C., Florida Building Code Adopted, must ensure that facility staff receive the following training. (a) Facility staff who have regular contact with or provide direct care to residents with ADRD, shall Page 35 of 43 ne obtain 4 hours of initial training within 3 months of employment. Completion of the core training program between April 20, 1998 and July 1, 2003 shall. satisfy this requirement. Facility staff who meets the requirements for ADRD training providers under ‘paragraph (g) of this subsection will be considered as i 1 i ‘ lar contact” means staff who interact on a daily basis with residents but do not provide direct care to residents. Initial training, entitled “Alzheimer’s Disease and Related Disorders Level I Training,” must address the following subject areas: 1. Understanding Alzheimer’s disease and related disorders; . 2. Characteristics of Alzheimer’s disease; 3. Communicating with residents with Alzheimer’s disease; 4, Family issues; 5, Resident environment; and 6. Ethical issues. (b) Staff who have received both the initial one hour and continuing three hours of ADRD training pursuant to ' Sections 400.1755, 429.917, and 400.6045(1), F.S., shall be considered to have met the initial assisted living facility Alzheimer’s Disease and Related Disorders Level I Training. (c) Facility staff who provide direct care to residents with ADRD must obtain an additional 4 hours of training, entitled “Alzheimer’s Disease and Related Disorders Level II Training,” within 9 months of employment. Facility staff who meet the requirements for ADRD training providers under paragraph (g) of this subsection will be considered as having met this requirement. Alzheimer’s Disease and Related Disorders Level II Training must address the following subject areas as they apply to these disorders: 1, Behavior management; 2. Assistance with ADLs; 3. Activities for residents; 4. Stress management for the care giver; and 5. Medical information. (d) A detailed description of the subject areas that must be included in an ADRD curriculum which meets the requirements of paragraphs (a) and (b) of this subsection can be found in the document “Training Guidelines for the Special Care of Persons with Page 36 of 43 Alzheimer’s Disease and Related Disorders,” dated March 1999, incorporated by reference, available from the Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, Florida 32399-7000. (e) Direct care staff shall participate in 4 hours of continuing education annually as required under Section 129,178 Tena , : . paragraph may be used to meet 3 of the 12 hours of continuing education required by Section 429.52, F.S., and subsection (1) of this rule, or 3 of the 6 hours of continuing education for extended congregate care required by subsection (7) of this rule. (10) ALZHEIMER'S DISEASE AND RELATED DISORDERS (“ADRD”) TRAINING PROVIDER AND CURRICULUM APPROVAL. (a) The training provider and curriculum shall be approved by the department or its designee prior to commencing training activities. The department or its designee shall maintain a list of approved ADRD training providers and curricula. Approval as a training provider and approval of the curriculum may be obtained as follows: 1. Applicants seeking approval as ADRD training ’ providers shall complete DOEA form ALF/ADRD-001, Application for Alzheimer’s Disease and Related Disorders Training Provider Certification, dated March 2005, which is incorporated by reference and available at the Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, Florida 32399-7000. 2. Applicants. seeking approval of ADRD curricula shall complete DORA form ALF/ADRD-002, Application for Alzheimer’s Disease and Related Disorders Training Three~Year Curriculum Certification, dated March 2005, which is incorporated by reference and available at the Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, Florida 32399-7000. Approval of the curriculum shall be granted for 3 years, whereupon the curriculum shall be re-submitted to the department or its designee for re-approval. (b) Approved ADRD training providers must maintain records of each course taught for a period of 3 years following each program presentation. Course records shall include the title of the approved ADRD training curriculum, the curriculum approval number, the number of hours of training, the training provider's name and approval number, the date and location of the course, and a roster of trainees. Page 37 of 43 os (c) Upon successful completion of training, the trainee shall be issued a certificate by the approved training provider. The certificate shall include the title of the approved training and the curriculum approval number, the number of hours of training, the trainee’s name, dates of attendance, location and the training f ’ : - i a oe The training provider’s signature on the certificate shall serve as documentation that the training provider has verified that the trainee has completed the required training pursuant to Section 429.178, F.S. (d) The department or its designee reserves the right to attend and monitor ADRD training courses, review records and course materials approved pursuant to this rule, and revoke approval on the basis of non-adherence to approved curriculum, the provider’s failure to maintain required training credentials, or if the provider is found to knowingly disseminate any false or misleading information. (6) Except as otherwise noted, certificates’ of any ADRD training required by this rule shall be documented in the facility’s personnel files. (f) ADRD training providers and training curricula which are approved consistent with the provisions of Sections 429.1755, 429.6045, and 429.5571, F.S., shall - be considered as having met the requirements of paragraph (9) (a) and subsection (10) of this rule. (12) TRAINING DOCUMENTATION AND MONITORING. (a) Except as otherwise noted, certificates, or copies of certificates, of any training required by this rule must be documented in the facility’s personnel files. The documentation must include the following: 1. The title of the training program; 2. The subject matter of the training program; 3. The training program agenda; 4. The number of hours of the training program; 5. The trainee’s name, dates of participation, and location of the training program; 6. The training provider’s name, dated signature and credentials, and professional license number, if applicable. (b) Upon successful completion of training pursuant to this rule, the training provider must issue a certificate to the trainee as specified in this rule. (c) The facility must provide the Department of Elder Page 38 of 43 oe ~~ Affairs and the Agency for Health Care Administration ‘with training documentation and training certificates for review, as requested. The department and agency reserve the right to attend and monitor all facility in-service training, which is intended to meet 108. On septenber 22 and 23, 2011, the Agency also conducted a complaint investigation survey of the Respondent. 109, Based on the Agency’s surveyor’s review of Respondent’ s records and interviews, the Agency determined that the Respondent failed to ensure that each member of Respondent's resident-care staff had the minimum applicable training. The records of five of Respondent’s employees were reviewed, and one employee was found to lack the minimum training required to _ provide care to residents in an assisted living facility, employee #5. Le 110. Respondent advertises that Respondent provides special care for persons with ADRD, or Respondent maintains a secured area as described in Chapter 4, Section 434,4.6 of the Florida Building Code, as adopted in Rule 9N-1.001, F.A.C., Florida Building Code Adopted, or both. 111. The Agency’s surveyor reviewed employee #5's record and found that employee #5 had a training certificate dated 8/26/11, for Alzheimer's training that appeared to be altered, with the employee’s name hand-written on the certificate, Page 39 of 43 ad ee Further review revealed some typed letters: and the hand-written _ employee's name, 112. The Agency’s surveyor’s interview with employees #1 the Agency’s surveyor’s observation of the training certificate being altered. (113. On 9/26/11 at 2:43 PM, the Agency’s surveyor interviewed the instructor who provided the Alzheimer’s training on 8/26/11. | The instructor stated that she did provide the training to members of Respondent’s staff on that August 26, 2011. The instructor stated that she always types. each participant’s name on the certificate, and that she never hand- writes their names. The instructor sent an electronic mail to the Agency's surveyor listing the names of all who attended the : training. However, the e-mail sent by the instructor failed to reveal employee #5's name as attending the training. WHEREFORE , the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described uncorrected class III violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. Page 40 of 43 on COUNT VIII REVOCATION 114, The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. of deficient performance for purposes of § 408.815(1) (d), Florida Statutes. 116. Paragraphs 32 through 52 show a demonstrated pattern of deficient performance for ee of § 408.815(1) (da), Florida Statutes. 117. Paragraphs 54 through 77 show a demonstrated pattern of deficient performance for purposes of § 408.815(1) (d), | -—.s- Florida statutes. 118. Counts III through VII are three or more cited class II deficiencies for purposes of § 429.14(1) (e)2, Florida | : Statutes. . 119, Each of Counts I through VII are a violation of this part, authorizing statutes, or applicable rules, for purposes of § 408.815(1) (c), Florida Statutes. 120. Each of Counts III through VII are an intentional or negligent act seriously affecting the health, safety, or welfare ofa resident of the facility, for purposes of §§ 408.815(1) (b) and 429.14(1) (a), Florida Statutes. Page 41 of 43 ad aad 121. Each of paragraphs 115 through 120 are a separate and distinct ground for revocation of Respondent's license as an assisted living facility. further demonstrated pattern of deficient performance for purposes of § 408.815(1) (d), Florida Statutes, warranting revocation of Respondent’s license as an assisted living facility. WHEREFORE, the Agency intends to revoke the License of Respondent, an assisted living facility in the State of Florida, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. NOTICE 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, whose telephone number is 850-412~3630. 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. Page 42 of 43 wee 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. 7003 1010 0001 3600 2831, 507 S.E. yt Avenue, Williston, FL 32696, and by regular U.S. to Aurora Martin, Administrator, October 2@ , 2011. Copies furnished to: r_ An Sunshine Corp., 1223 East Concord Street, Orlando, FL 32803, on les H. Harris s4istant General Counsel Fla. Bar. No. 817775 “Agency for Health Care Admin. 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 727-552-1944 (office) 727-552-1440 (facsimile) Anna Lopez, HFE Supervisor, Alachua Page 43 of 43 { a Martin, Administrator ). . Good Samaritan Retirement Home ‘S07 S.E. 2* avenue Williston, FL, 32696 ~ : i :

Docket for Case No: 12-001134