someneemnsy cs vw . U FILED STATE OF FLORIDA OOMAY 26 AMIO: 45 AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF ADMINISTRATIVE STATE OF FLORIDA, AGENCY FOR . CARINGS HEALTH CARE ADMINISTRATION, 00-4 BAO Petitioner, AHCA CASE NO.: 04-00-011-ALF vs. JONES SHELTER & CARE INC. Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY notified that after twenty-one (21) days from receipt of this Complaint, the Agency for Health Care Administration (hereinafter referred to as the “Agency”) intends to impose a civil penalty in the amount of $4,700.00 upon JONES SHELTER & CARE INC., (hereinafter referred to as “Respondent”). As grounds for the imposition of this civil penalty, the Agency alleges as follows: (1) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part Ii, Florida Statutes. (2) Respondent is licensed to operate as an Assisted Living Facility at 509 Palmetto Street, Jacksonville, Florida 32202, in compliance with Chapter 400 Part IL, Florida Statutes (1999), and Rule 58A-5, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400 Part III, Florida Statutes (1999), and provisions of 58A-5, Florida Administrative Code, in that it failed to correct seventeen (15) Class Ill deficiencies and two (2) Class IV deficiencies ermine \/ , ro) during a ALF and LMH follow-up inspection conducted on February 15, 2000. These deficiencies, set forth below, were previously cited at a biennial licensure and limited mental health inspection conducted on December 14, 1999, and constitute uncorrected deficiencies: (a) (L101) Through staff interview and resident record review revealed that each mental health resident has not been assessed and determined that they are able to live in an. ALF. This is a violation of Section 400.419(1)(c), Section 400.4075(3)(b), and Section 400.426(6), Florida Statutes (1999). Class III deficiency. Fine: $300.00. (b) (L102) The Respondent failed to ensure that all mental of the health residents had documentation provided by the Department of Children and families within 30 days of admission that the resident is a mental health resident. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.029(2)(c) 1, Florida Administrative Code. Class III deficiency. Fine: $300.00. (c) (L103) The Respondent failed to ensure that all of the mental health residents are covered by a community living support plan and there is no plan on file in the facility. This is a violation of Section 400.419(1)(c), and Section 400.4075(3)(a), Florida Statutes (1999). Class III deficiency. Fine $300.00. (d) (L103) The Respondent failed to ensure that all mental health residents had a cooperative agreement as required. This is a violation of Section 400.419(1)(c), and Section 400.4075(3)(a), Florida Statues (1999). Class II deficiency. Fine: $300.00. semen WW 1S (e) (A100) The Respondent did not maintain complete and accurate records that clearly outline the operations of the business, including residents trust funds and other property. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.021(1), Florida Administrative Code. Class HI deficiency. Fine: $300.00. (f) (A208) The Respondent emergency management plan had not been re-, submitted for review to the local emergency management agency at the time of the survey. This is a violation of Section 400.419(1)(d), Florida Statutes (1999), and Rule 58A- 5.024(1)@), Florida Administrative Code. Class IV deficiency. Fine: $100.00. (g) (A306) The Respondent did not have on file a copy of the Agreement for Alternate Care Certification (CF-ES Form 1006) for those residents receiving OSS funds. This is a violation of Section 400.419(1)(d), Florida Statutes (1999), and Rule 58A- 5.024(2)(a) 11, Florida Administrative Code. Class IV deficiency. Fine: $100.00. (h) (A505) Based on employee record review, it was determined that all staff members have not completed the requirements for HIV education. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.0191(3), Florida Administrative Code. Class Ill deficiency. Fine: $300.00. " (i) (A520) The Respondent failed to ensure that all staff members had documentation from a health care provider stating they are free of signs and systems of communicable diseases and tuberculosis. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.019(h), Florida Administrative Code. Class III deficiency. Fine: $300.00. cele aE \/ \/ @) (A608) The Respondent failed to ensure that an accurate Medication Administration Record was maintained. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.0182(6)(c), Florida Administrative Code. Class III deficiency. Fine: $300.00. (k) (A901) The Respondent did not ensure the interior and exterior of the building and grounds was reasonably attractive. Loose, cracked or peeling paint was not promptly - replaced, repaired or repainted to provide a satisfactory surface finish. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.022(1)(b), Florida Administrative Code. Class III deficiency. Fine: $300.00. (1) (A902) The Respondent did not ensure the furnishings were clean, in good repair and reasonably attractive. . This is a violation of Section 400.419(1(c), Florida Statutes (1999), and Rule 58A- 5.022(1)(c), Florida Administrative Code. Class III deficiency. Fine: $300.00. (m) (A904) The Respondent did not ensure that the residents’ living areas were free of unsafe accumulations. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.022(1)(e), Florida Administrative Code. Class I deficiency. Fine: $300.00. © (n) (A1008) The Respondent did not ensure that residents were allowed 60 square feet of unable floor space in their sleeping rooms and did not ensure a maximum of four (4) occupants per sleeping room. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.023(7), Florida Administrative Code. Class III deficiency. Fine: $300.00. Peseameregiaye: \w/ , wo (0) (A1010) The Respondent did not ensure that all residents were supplied with the minimum required furnishings in their living areas. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.023(9), Florida Administrative Code. Class III deficiency. Fine: 300.00. (p) (A1017) The Respondent did not ensure that all bathroom doors provided privacy. “ This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.023(10)(a), Florida Administrative Code. Class III deficiency. Fine: 300.00. (q) (A1024) Through observation and staff interview on the day of the follow-up inspection, there was not a satisfactory fire safety report for the facility completed within the last 365 days. This is a violation of Section 400.419(1)(c), and Section 400.441(1)(a) 2, Florida Statutes (1999). Class III deficiency. Fine: 300.00. (4) Notice was provided in writing to the Respondent of each of the above violations and the time frame for correction. The agency is authorized to impose this fine pursuant to Chapter 400.419(1)(c), Chapter 400.441(1)(a), and Chapter 400.4075(3), Florida Statutes (1999), and Rule 58A-5, Florida Administrative Code. (5) Respondent is notified that they have a right to request an administrative hearing pursuant to 120.57, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if they request a hearing. Chapter 59-1, Part II, Florida Administrative Code, constitutes the Agency’s procedural tules for administrative proceedings resulting from this complaint. In order to obtain a Pema Se ; oS) formal proceeding under Section 120.57(1), Florida Statutes, your request for an administrative hearing must conform to the requirements in Rule 28-5.201, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to dispute material issues of the fact in your request for a hearing may by treated by the Agency as election by you of an informal proceeding under Section 120.57 (2), Florida Statutes. All requests for hearing shall be made to the Agency for Health Care . Administration, and delivered to Agency for Health Care Administration, Building 3, Suite 3431, 2727 Mahan Drive, Tallahassee, Florida 32308; Attention: Michael O. Mathis, Senior Attorney. Payment of fines shall be sent to the Agency for Health Care Administration, P.O. Box 13749, Tallahassee, Florida 32317-3749. (Please reference the case number and facility name on the front of your check). (6) Respondent is further notified that failure to request a hearing within twenty- one (21) days of receipt of this complaint will result in an admission of the facts alleged in the complaint and the entry of a final order by the Agency. , CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereby was sent by U.S. Certified Mail, Return Receipt Requested, to Abdullah Shah, Administrator, Jones Shelter and Care, 509 E. Palmetto Street, Jacksonville, Florida 32202 on this atbhiay of Bop } > 2000. LA TD ‘ ( Karen Swann Area #4 Office Supervisor Division of Health Quality Assurance Agency for Health Care Administration 921 North Davis Street, Suite 115 Jacksonville, FL 32209 A eae a \w/ Copies furnished to: Michael O. Mathis, Esquire Senior Attorney Agency for Health Care Administration Mail Stop #3 2727 Mahan Drive Building 3, Suite 3408D Tallahassee, FL 32308 Finance & Accounting Agency for Health Care Administration Bldg. 2, 2" Floor 2727 Mahan Drive Tallahassee, Florida 32308 Abdullah Shah, Administrator Jones Shelter and Care 509 E. Palmetto Street Jacksonville, Florida 32202

Docket for Case No: 00-002220