Certified Article Number 710b 4575 1294 2050 ile SENDERS RECORD STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case no: 2002047675 6% 6396 LAKE CARE SYSTEMS INC D/B/A EDGEWATER AT WATERMAN VILLAGE Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter referred to as PETITIONER), by and through its undersigned counsel, and files this Administrative Complaint against LAKE CARE SYSTEMS INC D/B/A EDGEWATER AT WATERMAN VILLAGE, (hereinafter referred as RESPONDENT), pursuant to Sections 120.569 and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Respondent pursuant to Section 400.102(1)(d) and Section 400.23(8), Florida Statutes (2001), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 3. PETITIONER has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2001). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2001). PARTIES 5. PETITIONER is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. Respondent is and was at all times material hereto a licensed nursing home with a principal address of 300 Brookfield Ave, Mt. Dora, Florida 32757-9562, with assigned license H#SNF 1138096 COUNTI RESPONDENT FAILED HOLD FOODS AT THE REQUIRED TEMPERATURES IN ONE OF THREE FACILITY STEAM TABLES. 42 CFR §483.35 (2001) Section 400.022 Fla.Stat. (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) 7. PETITIONER re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein 8. On or about May 10, 2002, Petitioner conducted a survey at Respondent. The following findings resulted in the issuance of a Class III deficiency: Based on observation and staff interview, the facility failed to hold foods at the required temperature in one of three facility steam tables which may increase the risk of food borne illness. Findings: Interview on 5/10/02 at 11:20 am with dietary staff revealed food is delivered to the unit steam tables at approximately 11:30 am for meal service at 12:00 pm. Observation on 5/10/02 at 11:30 am revealed the food for the Atlantic Unit had been delivered to the unit, uncovered (unwrapped) and transferred to the steam table. Positioned directly above the food were heat lamps, that had not been turned on. Once facility staff had been alerted, the lamps were turned on revealing that two of the four lamps were nonfunctional. Food temperatures were taken and recorded by dietary staff at 11:50 am, prior to meal service. Seven of the 15 food items tested were being held below the required temperature of 140 degrees Farenheit. The following are the food items held below the required temperature, listed in degrees Farenheit: a) Sliced Turkey: 110, b) Com Beef: 110, c) Mashed Potatoes: 110, d) Fortified Mashed Potatoes: 110, e) Pureed Turkey: 120, f) Ground Turkey: 120, Green Beans: 120. Food items were not removed from the steam table to be reheated to the required temperature until dietary supervision was notified by this surveyor. Failure to hold foods at the required temperature may increase the risk of food borne ilJness. 9. Based on all of the foregoing, Respondent violated 42 CFR § 483.35, and/or Chapter 400.022 Fla.Stat. (2001) by failing to provide pharmaceutical services residents. Title 42 CFR § 483.35 states in pertinent part as follows: Sec. 483.35 Dietary services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. (h) Sanitary conditions. The facility must-- (1) Procure food from sources approved or considered satisfactory by Federal, State, or local authorities; (2) Store, prepare, distribute, and serve food under sanitary conditions; and (3) Dispose of garbage and refuse properly. Title 42 CFR 483.35 10. Pursuant to Section 400.23(8), Florida Statutes, the foregoing constitutes an isolated class Ill deficiency defined within said statue. This deficiency is defined in pertinent part as follows: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of deficiencies as (c) A class II deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed.. (Section 400.23(8), Fla.Stat. 2001-in pertinent part). 11. That Respondent was provided a mandatory correction date of March 28, 2002, from the survey of March 18, 2002 and this deficiency constitutes an uncorrected deficiency. 12. Pursuant to Section 400.23(8), Florida Statutes, PETITIONER may impose a $2,000 fine against Respondent for this deficiency. CLAIM FOR RELIEF WHEREFORE, PETITIONER respectfully requests the following relief: 1 confirm factual findings as delineated hereinabove. 2) Impose a $2000 fine against Respondent; 3) Grant any other general and equitable relief as deemed necessary in the furtherance of justice Agency for Health Care Administration DY Peberd Jisweh Saliba Richard Joseph Saliba, Esquire, As Senior Attorney Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5865 (office): (850) 921-0158 fax

Docket for Case No: 03-000396