STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, no . if 797 Petitioner, AHCA NO: 2002038351 vs. FAMILY EXTENDED CARE OF SARASOTA, INC., d/b/a CABOT RESERVE ON THE GREEN, 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 FAMILY EXTENDED CARE OF SARASOTA, INC., d/b/a CABOT RESERVE ON THE GREEN (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent in the amount of one thousand five hundred dollars ($1,500) which includes a survey fee of $500 pursuant to Sections 400.414(1) (a), 400.419(1) (c) and 400.419(9) Florida Statutes. (2001) 2. The Respondent was cited for the deficiency set forth below as a result of a biennial survey conducted on or about May 14 through May 15, 2002. The deficiency is a 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 Sarasota 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 4450 - 8° Street, Sarasota, Florida 34232. Respondent, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I RESPONDENT FAILED TO CONTACT THE RESIDENT’S FAMILY AND HEALTH CARE PROVIDER WHEN THE RESIDENT EXHIBITED A SIGNIFICANT CHANGE, SPECIFICALLY, RESIDENT’S UNSTABLE BLOOD SUGARS, VIOLATING RULE 58A-5.0182(1) (d), FLORIDA ADMINISTRATIVE CODE. CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. Based on resident record review, review of hospital records, interview with the health care provider, and interview with staff, it was determined that facility staff failed to contact a resident’s family and health care provider for one (1) resident (Resident #4), when the resident was exhibiting unstable blood sugars. 9, Facility staff failed to adequately document the resident’s condition, note appropriate interventions, or report the resident’s unstable blood sugar condition to the resident’s physician. 10. This is a violation of Rule 58A-5.0182(1)(d), Florida Administrative Code which requires that the facility contacts the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change. 11. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of one thousand dollars ($1,000) is authorized pursuant to Sections 400.414(1) (a) and 400.419(1) (b) Florida Statutes. 12. Notice was provided in writing to the Respondent of the above violation and the time frame for correction. COUNT II ADDITIONAL FEE UNDER SECTION 400.419(9), FLORIDA STATUTES 13. The Respondent has been cited for a Class II deficiency and therefore is subject to a survey fee of $500 pursuant to Section 400.419(9), Florida Statutes. 14. Notice was provided in writing to the Respondent of each of the above violation(s) 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 and survey fee against the Respondent pursuant to Sections 400.414(1) (a), 400.419(1) (b), and 400.419(9), Florida Statutes in the amount of one thousand five hundred dollars ($1,500). 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 (two pages). All requests for hearing shall be made to the attention of Michael Sasso, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr. N., 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, Wuckat xheoor Michael P. Sasso, Esquire AHCA ~- Senior Attorney Fla. Bar No. 0167363 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to Roy R. Lustig, Registered Agent for Cabot Reserve on the Green, 2600 Douglas Road, #908, Miami, Florida 33134, via postage paid U.S. Mail, Return Receipt No. 7000 0520 0016 6299 0287 and to Administrator, Cabot Reserve on the Green, 4450 — 8" street, Sarasota, Florida 34232, Return GH Receipt No. 7000 0520 0016 6299 0294, on October Z , 2002. Sc has# f shevoe Michael P. Sasso, Esquire Copies furnished to: Roy R. Lustig Registered Agent for Cabot Reserve on the Green 2600 Douglas Road #908 Miami, FL 33134 (U.S. Certified Mail) Administrator Cabot Reserve on the Green 4450 - 8 Street Sarasota, FL 34232 (U.S. Certified Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS#3 Tallahassee, FL 32308 (Interoffice Mail) Alberta Granger Assisted Living Facility Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS#30 Tallahassee, FL 32308 Michael P. Sasso AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330K St. Petersburg, Fl 33701

Docket for Case No: 02-004794