: FILER STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRA TEOKAY 26 AMIGO: 44 STATE OF FLORIDA, AGENCY FOR ADs Save HEALTH CARE ADMINISTRATION, Oe Nee 188 Petitioner, AHCA NO: 4-00-003-NEL vs. DELTA HEALTH GROUP, INC., d/b/a MANOR ON THE GREEN, ; . QO0-adAaAd 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 $3,000.00 upon DELTA HEALTH GROUP, INC., d/b/a MANOR ON THE GREEN (hereinafter referred to as “Respondent”). As grounds for the imposition of this civil penalty, the Agency alleges as follows: —O The Agency has jurisdiction over the Respondent pursuant to Chapter 400 | Part-I of Florida Statutes (1999) and Rule 59A-4, Florida Administrative Code. . 2) Respondent i is licensed to operate as an Nursing Home at 324 Wilder ~ Boulevard, Daytona Beach, Florida 32114, in compliance with Chapter 400 Part-II, Florida Statutes (1999), and Rule 59A-4, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400 Part I, Florida Statutes, and provisions of Rule 59A-4, Florida Administrative Code, in that it was cited for one (1) Class Il deficiency during the abbreviated inspection on March 28, 2000. . (a) (F324) The Respondent failed to ensure that each resident received the appropriate level of supervision, based on a accurate assessments and care planning, to prevent accidents/injuries or situations which would jeopardize the safety of the residents. This is in violation of Section 400.23, Florida Statutes (1999), and Rule 59A-4.1288, Florida Administrative Code. Class Il deficiency, Fine: $3,000.00. | (4) The above referenced violation constitutes grounds to levy this penalty pursuant to Chapter 400.23, Florida Statutes (1999), and Rule 59A-4. 1288, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a violation of minimum standards, rules, and regulations for the operation of a Nursing Home. (5) Notice was provided in writing to the Respondent of the above violation and the time frame for correction. (6) Respondent is notified that it has a right to request an administrative heating pursuant to Section 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 1 issued, and to present written evidence or argument if they requests a hearing. Chapter 59-1 Part I, Florida Administrative Code, constitutes the Agency” s procedural rules for administrative proceedings resulting from this complaint. In order to obtain a 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. VW ae Nad Failure to dispute material issues of the fact in your request for a hearing may be treated by the Agency as an 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 343 1, 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). (7) 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 hereof was sent by U.S. Certified Mail, Return Receipt Requested to Gus Murphy, Administrator, 324 Wilder Boulevard, Daytona Beach, Florida 32114, on this ott day of f\ pré Al _, 2000. Karen K. Swann Area Office Supervisor _ Health Quality Assurance Agency for Health Care Administration 921 Davis Street, Suite A-115 : Jacksonville, FL 32209 pe greet ie eeeppee o ee ergee cece oe vu: Copies furnished to: Michael O. Mathis, Esquire Senior Attorney — Agency for Health Care Administration 2727 Mahan Drive Building 3, Tallahassee, FL 32308-5403 Agency for Health Care Administration Finance & Accounting Department P.O. Box 13749 Tallahassee, Florida 32317-3749 Karen Swann Area Supervisor Health Quality Assurance Agency for Health Care Administration 921 North Davis Street, Suite A-115 Jacksonville, FL 32209 Gus Murphy, Administrator Manor on the Green, 324 Wilder Boulevard Daytona Beach, Florida 32114 cee merece: few _mmaepeee erm mmeereecge pope sorte:

Docket for Case No: 00-002222