ES: FLORIDA: rative Hearings AGENCY FOR HEALTH CARE ADMINISTRATION OCT 19 Ay STATE OF FLORIDA “AHC A AGENCY FOR HEALTH DEPARTMENT CLERK CARE ADMINISTRATION, Petitioner, vs. _ AHCA NO: 07-01-0144-NH BEVERLY HEALTHCARE LAKE MARY (Beverly Savana Cay Manor, Inc., d/b/a Beverly Healthcare Lake Mary), 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 $2500.00 upon Beverly Savana Cay Manor, Inc., d/b/a Beverly Healthcare Lake Mary (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 a nursing home at 701 North Sun Drive, ‘Lake Mary, Florida 32746, in compliance with Chapter 400, Part II, Florida statutes, and Chapter 59A-4, Florida Administrative Code. FILED _— reer cee (3) The Respondent has violated the provisions of Chapter 400, Part II, Florida Statutes, and provisions of Chapter 59A-4, Florida Administrative Code, in that it was cited for the deficiency set forth below during the survey of June 13, 2001: a) The Respondent failed to ensure that a resident who entered the facility without pressure sores did not develop them and failed to. provide necessary treatment and services to a resident who had developed pressure sores. This is a violation of Section 400.022(1) Florida Statutes; and Rule S9A-4.1288, Florida Administrative Code, adopting by reference 42 C.F.R. 483.25(c) (1) &(2) for which a fine is authorized under Section 400.23, Florida Statutes. Class II deficiency. Fine: $2500.00. (4) The above referenced violation[s] constitute[s] grounds to levy a civil penalty pursuant to Section 400.23, Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules and regulations for the operation of a nursing home. (5) Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. | (6) Respondent is notified that it has a right to request ‘an administrative hearing pursuant to Section 120.569, Florida : : j t i 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. Respondent may be entitled to mediation pursuant to Section 120.573, Florida Statutes. Requesting mediation is not a substitute for requesting a hearing. All requests for hearing shall be made to the Agency for Health Care Administration, Division of Health Quality Assurance, 525 Mirror Lake Drive North, suite 3103, St. Petersburg, FL 33701; Attention: Eileen O’ Hara Garcia, 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). eee ened SOR NOTE PRR NEER ap COO TRC pre b kb k k (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. I HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt (2 170 444 165) to Corporation Service Company, 1201 Hays Street, Tallahassee, FL 32301-2525, Registered Agent for Beverly Savana Cay Manor, Inc., on the 1 aay of elope , 200/_. Eileen O'Hara Garcia, Agency for Health Car Administration 525 Mirror Lake Drive North Suite 3107 St. Petersburg, FL 33701 (727) 552-1439 Copies furnished to: Eileen O'Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 3107 St. Petersburg, Florida 33701 Long Term Care Section Agency for Health Care Administration 2727 Mahan Drive : Tallahassee, Florida 32308 Area 7 Office a Agency for Health Care Administration Hurston Tower South 400 W. Robinson Street, S309 Orlando, Florida 33701 Finance & Accou g Agency for Health Care Administration 2727 Mahan Drive cre OCT re Tallahassee, Florida 32308 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive : Tallahassee, Florida 32308 Administrator Beverly Healthcare Lake Mary 701 North Sun Drive Lake Mary, Florida 32746 nee Spt ogee ener ads a ke Ae ek

Docket for Case No: 01-004529