STATE OF FLORIDA D4-H8 9 AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE, ADMINISTRATION, Patitioner, vs. BHCA NO; 07-01-0149-NH BEVERLY HEALTHCARE KISSIMMEE (Beverly Entexzprisas Florida, Inc., d/b/a Beverly Healthcara Kissimmee) , Respondent. / oe ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Adminiscration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against Beverly Enterprises Florida, Inc., d/p/a/ Beverly Healthcare Kissimmee (hereinafter Respondent” ) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of one thousand ($1,000) dollars pursuant to Sections 400.23 (8), 400,102(1) (a), (da), 400.121(1) Florida Statutes, 2. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part IT, Fierida Statutes. 3. Venue lies in Osceola County, Division of Administrative Hearings, purguant to Section 120.57 Florida Statutes, and Chapter 28-106.207 F.A.C. 3. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 590-4, Florida Administrative Code. 4, Respondent, Beveriy Healthcare Kissimmee, is a nursing home located at 1120 West Donegan Avenue, Kissimmee, Florida, The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code, COUNT I RESPONDENT FAILED TO PROVIDE CARE IN ACCORDANCE WITH A RESIDENT’S WRITTEN PLAN OF CARE 59A~-4.1289, F.A.C. and 42 CFR 483.20 (k) (3) (ii) CLASS III DEFICIENCY 5. AHCA re-alleges and incorporates (1) through (4) as if fully set forth herein, é. On or about June 14, 2001, the facility was cited for the deficiency set forth below. This deficiency was previously cited during a re-certification survey conducted on or about May 10, 2001, and sherefore, constitutes an uncerrected class fit deficiency. 7. Based upon surveyor observations, resident record reviews and interviews, it was determined that the facility failed to follow the pressure sors care plan of one out of ten sampled residents so that the highest practicable well being of the resident could be preserved. 8. The Respondent was given written potification of the ited deficiency containing a detailed description of the facts giving rise to the deficiency and the time frame for correction. 9. Based on the foregoing, Respondent violated 590-4.1288 F.A.C. adopting by reference 42 CFR 483.20(k) (3) (in), which requires that the services provided by the facility must be provided by qualified persons in accordance with each resident’s written plan of caze. This is a repeat class III violation. The Agency is authorized to impose 2 fine in the amount of $1,000.00 pursuant fo Sections 400.23(8)(c), 400.102(1) (a), (a), and 400.i121(1) Florida statutes. WHEREFORE, AHCA intends to impose a fine of one thousand dollars ($1,000) for the violation cited in Count I, against the respondent under Section 400.23(8) (c), Florida Statutes. The Respondent is notified that it has a4 right to request an administrative hearing pursuant to Section 120.543, Florida Statues (2001). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Flection of Rights (one page). Ail requests for hearing sheil he made to the attention of Dennis L. Godfrey, Senior Attorney, Agency for Health Care Administration, 525 Mitror 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. AHCA - Senior Attorney 525 Mirror Lake Drive North Sebring Bldg., Suite 3101 9t. Petersburg, Florida 33701 (727) 552-1525 .T HEREBY CERTIFY that @ true copy hereof was sent by U.S. Certified Mail, Return Receipt No. 2 176 444 503, to Corporation Service Company, 1201 Hays Street, Tallahassee, FL 32301-2525,. Eee Registered Agent for Beverly enterprises Florida, Inc., on the Way of Plier», 2001. Godirey, Copies furnished ta: Long Term Care Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32304 Area 7 Office Agency for Health Care Administration Hurston Tower South 400 W. Robinson Street, $309 Orlando, Florida 33701 Pinance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 323098 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive Tallahaseee, Florida 32308 Administrator Beverly Healthcare Kigsimmee 1120 West Donegan Avenue Kissimmee, Florida

Docket for Case No: 02-003489