STATE OF FLORIDA ee cee am AGENCY FOR HEALTH CARE ADMINISTRATION | 7} 03 HAY 27 PM uy: 04 AGENCY FOR HEALTH CARE cys ADMINISTRATION, Apais : AUT arn on #t, Petitioner, vs. Case No. 2003000796 NATHANIEL GALLON d/b/a, O%>-191{ ORCHARD MEADOWS, ~ Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against NATHANIAL GALLON d/b/a, ORCHARD MEADOWS, hereinafter referred to as “Respondent,” pursuant to Section 120.569, and 120.57, Fla. Stat., (2002), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine upon the Respondent, pursuant to Section 400, Part III, Fla. Stat., (2002). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to § 120.569 and 120.57, Fla. Stat. (2002). 3. AHCA has jurisdiction over the Respondent pursuant to Chapter 400, Part IIL, Fla. Stat. (2002). 4. Venue shall be determined pursuant to Fla. Admin. Code R. 28-106.207 (2002). PARTIES 5. Pursuant to Chapter 400, Part III, Fla. Stat. (2002), and Fla. Admin. Code R. 58A-5, (2002) AHCA is the licensing and enforcing authority with regard to assisted living laws and rules. 6. The Respondent is an assisted living facility located at 865 N. Wakeenah Street, Monticello, FL, 32345. The Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part Il, Fla. Stat. (2002), and Fla. Admin. Code R. 58A-5, (2002) having been issued license number 8362. COUNT I The Respondent failed to maintain a safe, hazard free environment in 7 out of ten rooms observed, which had hot water temperatures that ranged from 122 degrees to 139 degrees Fahrenheit. Fla. Admin. Code R. 58A-5.023(1)(a) (2002) § 400.428(1)(a), Fla. Stat. (2002) 7. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. " 8. On or about January 31, 2003, AHCA conducted a survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a) Based on observation and interviews, Respondent failed to maintain a safe, hazard free environment as evidenced by 7 out of 10 rooms observed were found to have a water temperatures that ranged from 122 degrees Fahrenheit to 139 : degrees Fahrenheit. 9. The Respondent failed to ensure the a safe hazard free environment, as required by § 400.428 (1) (a), Fla. Stat. (2002); and Fla. Admin. Code R. 58A- 5.023(1)(a), (2002) which states: 58A-5.023 Physical Plant Standard. (1) General requirements. (a) The ALF shall be located, designed, equipped, and maintained to promote a residential, non- medical environment, and provide for the safe-care and supervision of all residents. 10. The foregoing violation constitutes a Class I violation. Class I violations are those conditions or occurrences related to the operation and maintenance of a building or required reports, forms, or documents that do not have the potential of negatively affecting residents. These violations are of a type that the Agency determines Class "I" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines present an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional harm would result therefrom. This violation is subject to an administrative fine in an amount not less than $5,000 and not exceeding $10,000 for each violation. A fine may be levied notwithstanding the correction of the violation. 11. The mandated correction date was January 31, 2003. 12. The violation alleged herein constitutes an uncorrected Class I deficiency, and warrants a fine of $5,000. COUNT II The Respondent failed to provide Level I background screenings for 7 out of 9 staff/volunteers who provide personal care services to the residents. Fla. Admin. Code R. 58A-5.0193(3) (2002) § 400.4174(2), Fla. Stat. (2002) 12. AHCA re-alleges and incorporates paragraphs one (1) through six (6) as if fully set forth herein. ww 13. On or about January 31, 2003, AHCA conducted a survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a) Based on record reviews and interviews, it was determined that the facility failed to ensure that 7 out of 9 staff/volunteers who provide personal care services to residents were in compliance with Level 1 background screening requirements. b)Per interview with the administrator on or about January 31, 2002, she : confirmed that seven of her staff/volunteers who provide personal care services to the residents had not had a Level 1 background screening. 14, The Respondent failed to provide Level 1 background screenings for 7 out of 9 staff/volunteers who provide personal care services to the residents violating Fla. Admin. Code R. 58A-5.0193(3) (2002) and § 400.4174(2), Fla. Stat. (2002). 15. The foregoing violation constitutes a Class IL violation. Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. A class II violation is subject to an administrative fine in an amount not less than $1,000 and not exceeding $5,000 for each violation. 16. The Respondent was provided a mandated correction date of February 10, 2003. The violation alleged herein constitutes a Class II deficiency, and warrants a fine of $1000.00. COUNT Ill SURVEY FEE PURSUANT TO SECTION § 400.419(9), Fla. Stat. (2002) 17. The Respondent was cited for the above Class I and a Class II deficiency as the result of a biennainal survey. The agency is entitled to assess a survey fee, equal to the lesser of one half of the facility’s biennial license and bed fee or $200, to cover the ' cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 400.428(3)(c) to verify the correction of the violations. 18. Agency assesses a survey fee against the Respondent in the amount of two hundred dollars ($200.00) pursuant to § 400.419(9) F.S. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this Administrative Complaint; 2. a) Impose an administrative fine of $5000.00 against the Respondent for violation in Count J; ' b) Impose an administrative fine of $1000.00 against the Respondent for violation in Count UJ; and c) Assess a survey fee of $200.00 against the Respondent for Count II; and 3. All other general and equitable relief allowed by law. Submitted on this (97” day of Match 2003, on behalf of the Agency for Health Care Administration by, Af fos Ursula Eikman, Esquire Staff Attorney, Fla. Bar. No. 0500941 Agency for Health Care Administration 2727 Mahan Drive Bldg. 3, MSC #3 Tallahassee, Florida 32308 (850) 922-5865 (office)/ (850) 413-9313 (fax) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2003000796 NATHANIEL GALLON, d/b/a ORCHARD MEADOWS, Respondent. / NOTICE The Respondent, NATHANIAL GALLON d/b/a, ORCHARD MEADOWS,, is hotified that it has a right to request an administrative hearing pursuant to Section’ 120.569, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights form and explained in the attached Explanation of Rights form. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308; Attention: Ursula Eikman Esquire- Staff Attorney. THE RESPONDENT IS FURTHER NOTIFIED, if the request for hearing is not received by the Agency for Health Care Administration within twenty-one (21) days of regeipt of this Administrative Complaint, a Final Order will be entered. pot Submitted on this _/ 7 "day of Maa th 2003, on behalf of the Agency for Health Care Administration by, , ff é u Pb Chime Ursula Eikman, Esquire Staff Attorney, Fla. Bar. No. 0500941 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC#3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5865 (office) (850) 413-9313 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights form have been sent by U.S. Certified Mail, Return Receipt Requested (return receipt #4ow cuce verze 7825 °F! fo NATHANIAL GALLON d/b/a, ORCHARD MEADOWS,,.P.O. Box 1008/Rt. Box 126-c, Monticello, FL 32345. ; Submitted on this __/ qt "tay of Mu iq h 2002, on behalf of the Agency for Health Care Administration by ; ik Unrate CaP pe Ursula Eikman, Esquire Staff Attorney, Fla. Bar. No. 0500941 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC#3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5865 (office) (850) 413-9313 (fax) ;

Docket for Case No: 03-001971