STATE OF FLORIDA AGENCY FOR HEALTH CARE PUTER 0 vg STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 07-01-0077-NH vs. BEVERLY HEALTHCARE RIO PINAR (Beverly Enterprises Florida, Inc., d/b/a Beverly Healthcare Rio Pinar), 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 $3000.00 upon Beverly Enterprises Florida, Inc., d/b/a Beverly Healthcare Rio Pinar (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 7950 Lake Underhill Road, Orlando, Florida 32822, in compliance re OOP OPO WRT pre ot LTT RT ETE RET RE REET TET RT with Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. (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 deficiencies set forth below during the survey of February 22, 2001. These deficiencies were previously cited at the annual survey of January 11, 2001, and constitute uncorrected deficiencies: a) The services provided by the facility failed to meet professional standards of quality. The technique of observed medication administration was below professional standards of quality with respect to hand washing, privacy and handling of gastrostomy tube feedings. This is a violation of Rule 59A-4.1288, F.A.C. adopting by reference 42 CFR 483.20(k) (3) (i), for which a fine is authorized under Section 400.23, Florida Statutes. Class III deficiency. Fine: $1000.00. b) The facility did not store and distribute cold food under proper holding temperatures. This is a violation of Rule 59A-4.1288, F.A.C. adopting by reference 42 CFR 483.35(h) (2), for which a fine is Siatacaal PO RRIRET OCTOREREREE eORRT RIE cee REESE RTT REET cE oF re Sd AA ER es A i apes authorized under Section 400.23, Florida Statutes. Class III deficiency. Fine: $1000.00. c) The facility failed to ensure that drugs and biologicals were in locked compartments and accessible only to authorized personnel. This is a violation of Rule 59A-4.1288, F.A.C. adopting by reference 42 CFR 483.60(e) (1), for which a fine is authorized under Section 400.23, Florida Statutes. Class III deficiency. Fine: $1000.00. (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 the above violation(s) and the time frame for correction. WHEREFORE, AHCA intends to impose a fine of three thousand dollars ($3,000) for the violations cited above, against the respondent under Section 400.23(8)(c), Florida Statutes. SRR re re 9 TOT RET RE FEE TE AE FTE RRR EPTFE RR FOAL The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2001). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to ‘the attention of Dennis L. Godfrey, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. 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. R ectfully submitted, AHCA - Senior Attorney 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 I HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt No. 2 259 496 222 , to Corporation Service Company, 1201 Hays Street, Tallahassee, TERT I RRE rere lt i tl GN I A kh ld FL 32301-2525, Registered Agent for Beverly Enterprises Florida, Inec., on the day of , 2001. Dennis L. Godfrey, Esquire Copies furnished to: Long Term Care Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 vere Area 7 Office Agency for Health Care Administration Hurston Tower South 400 W. Robinson Street, $309 E Orlando, Florida 33701 i 7 meme 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 Administrator Beverly Healthcare Rio Pinar 7950 Lake Underhill Road Orlando, Florida 32822 02 JAN 29 ANTI: 09 oly PAYMENT FORM Agency for Health Care Administration Finance & Accounting P.O. Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , which represents Payment of the administrative fine imposed by AHCA. Facility Name AHCA No. cc: Dennis L. Godfrey, ESQ. Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive North Room 310L St. Petersburg, FL 33701 wee rr TORE RE ek i i i iil Eh A

Docket for Case No: 02-000360