LAd- Bad roOTAN STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION I DS STATE OF FLORIDA eran LAP eB « AGENCY FOR HEALTH CARE eh ONT ULE ADMINISTRATION, Co Petitioner, ~ 029891 vs. . ° LL HEALTH CARE PROPERTIES XV, Cee 2 LTD. d/b/a WELLINGTON PLACE fae OF ORMOND BEACH, ce 5 2 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 Health Care Properties XV, Ltd. d/b/a Wellington Place of Ormond Beach (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent in the amount of five hundred dollars ($500) pursuant to Sections 400.419(1)(c), ~and 400.414(1)(a). . 2. The Respondent is cited for the deficiency set forth below as a result of follow-up survey on or about April 22, 2002. The original deficiency was sited at the annual survey conducted on ot about February 19, 2002. The deficiency is an uncorrected Class II deficiency. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 4, Venue lies in Volusia County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. PARTIES 5. AHCA, Agency for Health Care Administration, State of Florida is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 1050 Ocean Shore Blvd, Ormond Beach, FL 32176. Respondent, is and was at all times material hereto, a licensed faci lity under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I RESPONDENT FAILED TO REFILL RESIDENT’S PRESCRIPTIONS IN TIMELY MANNER. VIOLATING 58A-5.0185(7)(f), F.A.C. CLASS I DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. - Based on record review, interview and observations it was discovered that the Respondent failed to refill medications for 1 of 4 sampled residents (#1). Resident #1’s medication observation record (MOR) and staff interview revealed orders for Vitamin C 500 mg, one tablet twice a day; multi-vitamin with iron, one twice a day; Vasotec 10 mg., one twice a day; Prevacide 30 mg. one every moming. Surveyors observed records on the day of survey that indicated the Multi-vitamin and the Vitamin C were circled as not for eight days and Vasotec and Prevacid were not given for ten days. 9. This is a violation of 58A-5.0185(7)(, Florida Administrative Code, requiring pursuant to s. 400.441, Florida Statutes, Respondent to make every reasonable effort to ensure that prescriptions for residents who receive assistance with self- administration or medication administration are refilled in a timely manner. 10. The above referenced violation constitutes the grounds for the imposed Class III deficiency and for which a fine of five hundred dollars ($500) is authorized pursuant to Section 400.419(1)(c), Florida Statutes. 11. Notice was provided in writing to the respondent of the above violation and the time frame for correction. WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order relief with a fine against the Respondent pursuant to Sections 400.419(1)(c), and 400.414(1)(a), Florida Statutes in the amount of five hundred dollars ($500). The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. 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 Ursula Eikman, AHCA, Bldg. 3, SC#3, 2727 Mahan Drive, Tallahassee, FL, 32308. 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, — Unsele. CL Ursula Eikman, Esquire Assistant General Counsel Florida Bar I.D. 0500941 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308 (850) 922-5873 (office) I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail Return Receipt No. 7106 4575 1294 2050 4598, to Marilyn Couzens, Administrator, Wellington Place of Ormond Beach, 1050 Ocean Shore Blvd, Ormond Beach, FL 32176, on the 2S "ay of June, 2002. URSULA EIKMAN, Esquire UE/sr STATE OF FLORIDA - AGENCY FOR HEALTH CARE ADMINISTRATION 25° z a RE: CASE NAME teaith Care Properties XV, Ltd., d/b/a Wellington Place of Ormond Beach . CASE NO(s). 2002029891 é ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) 6 ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought: __ . - OPTION TWO (2) 6 1 do not dispute and | admit the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2). Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency im mitigation of the penalty imposed. OPTION THREE (3) 6 /do dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Adiministrative Law Judge appointed by the Division of Administrative Hearings. If you choose OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. If you have elected either OPTION TWO (2) or THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. 6 Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO PAYMENT NOW -- REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES {Please sign and fill in your current address. ) Respondent (Licensee) Address _ License. No. and facility type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Ursula Eikman, Esq., Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32301. (Note: Overnight Deliveries to Ursula Eikman, Esq., AHCA, 2727 Mahan Dr., MS #3, Tallahassee, FL 32308-5403.) Telephone Number: 850/922-5873; FAX 850/413-9319; TDD 1-800-955-8771. RN STATE OF FLORIDA - AGENCY FOR HEALTH CARE ADMINISTRATION .. ° & 5 rae > we (To be used with Election of Rights for Administrative Complaint form — attached) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA” or “Agency’), you must make one of the following elections within twenty- one (21) days from the date of receipt of the Administrative Complaint. Please make your election of the attached Election of Rights form and retum it fully executed to the address listed on the form. OPTION 1. If you do not dispute the allegations in the Administrative Complaint and waive your right to be heard, you should select OPTION 1 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Complaint. You will be provided a copy of the final order. OPTION 2. If you do not dispute any material fact alleged in the Administrative Complaint (you aden each of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes peture tne Agency. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing you — should select OPTION 2 on the Election of Rights form. OPTION 3. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to a hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. if you do not respond at all within twenty- one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint.

Docket for Case No: 02-003029