L9- 1302. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 08-01-0348-NH FRAES NO: 2001067021 GULF CARE, INC., d/b/a GULF COAST VILLAGE CARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Gulf Care, Inc., d/b/a Gulf Coast Village Care Center, (herein after “Respondent” ) and alleges: Nature of the Action 1. This is an action to impose an administrative fine in the amount of five thousand dollars ($5,000) pursuant to Sections 400.23(8) (b), and 400.102(1) (d), Florida Statutes. 2. The respondent was cited for the Class II deficiency, set forth in Count I _ below, as the result of a complaint investigation survey conducted on or about November 01, 2001. Jurisdiction and Venue 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4, Venue lies in Lee County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28 F.A.C. Parties 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 1333 Santa Barbara Blvd., Cape Coral, Florida. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO ENSURE THAT ONE RESIDENT WAS PROVIDED SUFFICIENT FLUIDS TO PREVENT DEHYDRATION ANI) URINARY TRACT INFECTION, VIOLATING Rule 59A-4.1288, F.A.C. ADOPTING BY REFERENCE 42 CFR 483.25(3) CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Based upon interviews with the Director of Nursing and the resident as well as facility and hospital record reviews, it was determined that the facility failed to ensure that Resident #2 received sufficient fluid intake to prevent dehydration and urinary tract infection. 9. This is a violation of Rule 59A-4.1288 F.A.C. adopting by reference 42 CFR 483.25(j) requiring the facility to provide each resident with sufficient fluid intake to maintain proper hydration and health. 10. The Agency seeks to impose a fine upon the respondent in the amount of five thousand ($5,000) for this Class II deficiency pursuant to Section 400.23(8) (b) Florida Statutes. WHEREFORE, AHCA intends to impose a fine against the respondent in the amount of five thousand dollars ($5,000) for the above referenced violation, pursuant to Section 400.23(8) (b) Florida Statutes. 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. Respectfully submitted, Kennis L. Godfrey, AHCA -— Senior Attorng 525 Mirror Lake Drivé North, St. Petersburg, Florida 33701 I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail Return Receipt No. Z 593 748 991, to Gulf Care, Inc., through its Registered Agent, Richard C. Heath, 1333 Santa Barbara Blvd., Cape Coral, FL. 33991 on the 28, day of January, 2002. his L. Godfrey, Esq Copies furnished to: Richard C. Heath 1333 Santa Barbara Blvd. Cape Coral, Florida 33991 (U.S. Certified Mail) Administrator Gulf Coast Village Care Center 1333 Santa Barbara Blvd. Cape Coral, Fl. 33991 (U.S. Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration (Inter-office mail) Dennis L. Godfrey, Esq. AHCA - Senior Attorney 525 Mirror Lake Drive N. #310L St. Petersburg, Florida 33701

Docket for Case No: 02-001302