STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 06-01-0139-ALF SOUTHERN GARDENS OF LAKE ALFRED, INC., d/b/a SOUTHERN GARDENS ALF, Respondent. ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from the 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 $12,000.00 upon Southern Gardens of Lake Alfred, Inc., d/b/a Southern Gardens ALF (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 III, Florida Statutes. (2) Respondent is licensed to operate as an Assisted Living Facility at 255 E. Main Street, Lake Alfred, Florida 33850, in compliance with Chapter 400, Part III, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. (3) The Respondent has violated minimum licensure standards, as evidenced by each deficiency set forth below, as found to exist during the survey of June 12, 2001: (a) The Respondent failed to have enough qualified staff to provide resident supervision in accordance with their scheduled and unscheduled service needs. This is a violation of Section 400.419(1) (b), Florida Statutes, and Rule 58A-5.019(4) (b), Florida Administrative Code. Class II deficiency. Fine: $1,000.00. (ob) The Respondent failed to provide care and services appropriate to the needs of the resident listed as Resident 9 on the June 12, 2001 survey. This is a violation of Section 400.419(1) (a), Florida Statutes, and Rule 58A-5.0182, Florida Administrative Code. Class I deficiency. Fine: $5,000.00. (c) ‘The Respondent failed to ensure that all employees who perform personal services to residents have the Level 1 background screening. e Ge ~ This isa violation of Sections 400.419(1) (b), 400.4174(2) and 400.215, Florida Statutes, and Rule 58A-5.019(3), Florida Administrative Code. Class II deficiency. Fine: $1,000.00. (d) The Respondent failed to ensure that staff who provide direct care to residents receive a minimum of one hour in-service training covering emergency procedures within 30 days of employment. This is a violation of Section 400.419(1) (bo), Florida Statutes, and Rules 58A-5.0191(2) (b) and 58A~5.0192(10) (e), Florida Administrative Code. Class II deficiency. Fine: $1,000.00. (e) The Respondent failed to ensure that there was at least one staff member within the facility at all times when residents are in the facility, who is trained in First Aid and CPR. This is a violation of Section 400.419(1) (b), Florida Statutes, and Rule 58A-5.019(4) (a)4, Florida Administrative Code. Class II deficiency. Fine: $1,000.00. (£) The Respondent failed to comply with the Resident Bill of Rights. Specifically, the facility changed _a_resident’s dining seating assignment without the the resident’ s approval and refused a resident : permission to leave the facility. This is a violation of Sections 400.419(1)(b) and 400.428(1), Florida Statutes. Class It deficiency. “Fine: $1,000.00 at aie ob Be re * (g) The Respondent failed to ensure that all staff members are trained in their duties and are responsible for implementing the emergency management plan. This is a violation of Section 400.419(1) (b), Florida Statutes, and Rule 58A-5.026(3) (a), Florida Administrative Code. Class II deficiency. Fine: $1,000.00. (h) The Respondent failed to ensure that personnel records contain documentation of compliance with Level 1 background screening for all the staff members as required. This is a violation of Sections 400.419(1) (b) and 400.4275(2), Florida Statutes, and Rule 58A~5.024 (2) (a)2, Florida Administrative Code. Class II deficiency. Fine: $1,000.00. (4) The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.419, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an ALF (Assisted Living Facility). (5) Notice was provided in writing to the Respondent of each of the above violations and the time frame for correction. See er creme er (6) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, 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 it requests a hearing. Chapter 59-1, Part II, 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 28-106, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to dispute material issues of 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 Division of Managed Care and Health Quality, 525 Mirror Lake Drive North, Suite 310J, st. Petersburg, Florida 33701; attention Patricia J. Hakes, 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). peepee eee Spake BR rrud we eb Rakes comrR REE Fe (7) RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEPT 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. I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail and interoffice mail, Return Receipt (Z 170 444 472) Requested, to Southern Gardens of Lake Alfred, Inc., through its Registered Agent Judy Kelly, Southern Gardens ALF, 255 E. Main Street, Lake Alfred, Florida 33850, on the 25%, day of fabs , 2001. SRR. PATRICIA RE UFMAN Field Office Manager Agency for Health Care Administration Division of Managed Care and Health Quality Copies furnished to: Patricia J. Hakes, Esquire Agency for Health Care Administration “525 Mirror Lake Drive North, Suite 310g St. Petersburg, Florida 33701 ALF Section | Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Fl id, 32308 Area 6 Office. Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 410A St. Petersburg, Florida 33701 rrererenies SSR Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 hoe eae > tiiaccautcastammand

Docket for Case No: 01-003614