STATE OF FLORIDA ” SED AGENCY FOR HEALTH CARE ADMINISTRATION U7 /7 2 ¥ 20 Pi 77 / STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 05-01-0155-ALF THE VILLA CABANA, Respondent. ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fine in the amount of $1,000.00 upon The Villa Cabana (“Respondent”). As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part III, Florida Statutes. 2. Respondent, The Villa Cabana, is licensed to operate as an assisted living facility at 2600 Fourth Street South, St. Petersburg, Florida 33705, in compliance with Chapter 400 Part III, Florida Statutes, and Rule 58A-5, Florida Administrative Code. 3. The Respondent has violated the provisions of Chapter 400, Part III, Florida Statutes, and provisions of 58A- 5, Florida Administrative Code, in that it was cited for two (2) deficiencies during the survey of July 10, 2001. These deficiencies, set. forth below, were previously cited during a survey on July 13, 1999 and constitute repeat deficiencies: (a) The Respondent failed to train direct care staff in the reporting of major incidents or in facility emergency procedures. This is a violation of Section 400.419(1)(c), Florida Statutes, and Rules 58A-5.0191(2) (b), and 58A-5.0191(10) (e), Florida Administrative Code. Class III Deficiency. Fine $500.00. (b) The Respondent failed to ensure that any change in directions for use of a medications for which the facility is providing assistance with self- administration or administering medication, be accompanied by a written medication order issued and signed by the resident’s health care provider. This is a violation of Section 400.419(1)(c), Florida Statutes, and Rule 58A-5.0185(7)(d), Florida Administrative Code. Class III Deficiency. Fine $500.00. 4. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.414, Florida Statutes, and Rule 58A-5.033, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an Assisted Living Facility. 5. Notice was provided in writing to the Respondent of each of the above violations and the time frame of correction. 6. Respondent is notified that it has a right to request an administrative hearing 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 issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: Michael P. Sasso, Senior Attorney, 525 Mirror Lake Drive North, Room 310G, St. Petersburg, Florida 33701. All payment of fines should be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashier’s checks, and money orders should identify the AHCA number and facility name that is referenced on page 1 of this complaint. All payment of fines should be sent to the Agency for Health Care Administration, P.O. Box 13749, Tallahassee, Florida 32317-3749. 7. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Mail, Return Receipt (2 170 444 478) Requested, to Keith Young, Administrator, The Villa Cabana, 2600 Fourth Street South, St. Petersburg, Florida 33705, this BI day of JL , 2001. SAP vicave é Yan, PATRICIA REID CAI Field Office Manager Division of Managed Care And Heaith Quality Agency for Health Care Administration 525 Mirror Lake Drive North Sebring Building, Room 410A St. Petersburg, FL 33701 Copies furnished by internal mail to: Michael P. Sasso, Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive North, Room 310G St. Petersburg, Florida 33701 ALF Unit Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area 5/6 Office Agency for Health Care Administration 525 Mirror Lake Drive North, Room 410A St. Petersburg, Florida 33701 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 ecapgergecme conpemnp pense

Docket for Case No: 01-004079