f ,dun-01-2001 12:14pm From-LEGAL + 1601 ~207-480 1 1-327 p.onz/o0s °F-4ds oe” : STATE OF FLORIDA and %@, Ce, AGENCY FOR HEALTH CARE ADMINISTRATION Dy Ye, @ Qo gTaTE OF FLORIDA, AGENCY FOR o Us ig My , HEALTH CARE ADMINISTRATION, Uyfeg on Lo Co Af AHCa NO: 04-01-023-NH * Ol- 90] Petitioner, vs. BEVERLY ENTERPRISES FLORIDA, INC., d/b/a BEVERLY HEALTHCARE DELTONA, Respondent. f a ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED thas after rwenty-ont Gly ays from receipt of this Complaint, the Agency for Health Care Adminisration hereinafter referred to as the “Agency”) intends to impose 4 civil penalty in the amount $1,000.00 upon BEVERLY ENTERPRISES FLORIDA, INC., d/b/a BEVERLY HEALTHCARE DELTONA, (hereinafter referred 10 as “Respondent”), As grounds for the imposirion af this civil penalty, the Agency alleges as follows: Q) The Agency has jurisdiction aver the Respondent pursuant to Chapter 400 Par-Il, of Florida Stamutes (2000) and Rule 504-4, Florida Administrative Cade. (2) Respendent is licensed to operate as a Nursing Home at 1851 Elkcam Boulevard, Deltona, Florida 32725, in compliance with Chapter 400 Part ll, Florida Starutes (2000), and Rule 394-4, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapver 400 Part I, Florida Sramutes (2000), and provisions of Rule 59A-4, Florida Administrative Code, in that it - 7 # / Jun-01-2001 V2st4on From-lEGAL = V-Sol-goI-dett Tae .o0e/ans was cited for one (1) class Ul deficiency during the a complaint investigation on February 19, 2001. These deficiency set forth below, were previously cited during an annyal survey that was cited one (1) class HI deficiency during 2 complaint investigation on February 19, 2001. This deficiency set forth below, were previously cited at the survey on , Seprember 15, 2061, and constitutes, repeat deficiency. (F312) The ie Respondent failed to ensure thar all residents received the necessary services To iaintain good nutrition. This is in violation of Section 400.23, and Section 483.25 (2)(3), Florida Statutes (2000), and Rule 59A-4.1288, Florida Administrative Code. Class {II deficiency. Fine: $1,000.00. (4) The above referenced violation constitutes grounds to levy this penalty pursuant to Chapter 400.23, Florida Statutes (2000), and Rule 539A-4.1288, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes 4 violation of minimum standards, rules, and regulations for the operation ofa Nursing Home. . (5) Notice was provided in writing to the Respondent of the above violation and the time frame far correction. {8} Respondent is s notified that it has a right to request an administrative hearing Fedd§ pursuant 10 Section 120.87, Florida Statues, to be represented hy counsel (at its expense), | 10 take testimony, to call or cross-examine witnesses, 1a have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if they requests a hearing. The election and explanations of rights are attached and incorporated by reference and will substiture pursuant fo 120.57 Flarida Statutes. Al) requests for Jun-01-2001 12:14pm From-LEGAL : Na 801-201-480" ~ T3927) P.004/008 = F445 hearing and payment af fines shall be made to the Agency for Health Care Administration, Office of Licensure and Certification, Attention: Michael O. Mathis, Senior Attorney. Payment of fines shall be sent to the Agency for Health Care Administration, P.O. Box 13749, Tallahassee, Flonda 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 ane (23) days of receipt of this complaint will resul: in an admission of the facts alleged in the complain« and the entry of a final order by the Agency. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a tue copy hereof was sent by U.S. Cernfied Mail, Rerurn Receipt Requested to Mary Frances Pitenti, Administrator, 1851 Elkcam Boulevard, Delton, Florida 32725, on this AA dayot Meo , 2001. Bn Kareh K. Swann Area Office Supervisor Health Quality Assurance Agency for Health Care Administration 921 Davis Street, Suite 4-115 Jacksonville, FL 32209 _ Copies furnished ta: Michael O. Mathis, Esquire — : ; Senior Attorney Mary Frances Piretti, Administrator Agency for Health Care Administration 1831 Elkcam Boulevard o 2727 Mahan Drive Deltona, Florida 32725 Building 3, Suite 3408D Tallahassee, FL 32308-5403 prepene tee ad , gsr rim ee Jan-01-2801 12:18pm From-LEGAL 5 Agency for Health Care Administration Finance & Accounting Deparment P.O. Box 13749 Tallahassee, Florida 32317-3749 Karen Swann Area Supervisar Health Quality Assurance Agency for Health Care Admunistration 921 North Davis Street, Suite A-115 Jacksonville, FL 32209 1-501-201-480" » 1-327 P.005/005 F-445 3 Pee RR Ieper eR er arr”

Docket for Case No: 01-002701