T ) SB LAEIURG STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, 2003 O3b0 0603 3804 3745 Petitioner, vs. Case No. 2004000518 NORTH PORT RETIREMENT 2 CENTER, INC., i 3 d/b/a NORTH PORT RETIREMENT : “ CENTER, oOo, Respondent. ; OO / as is w A DMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and fi les this Administrative Complaint against NORTH PORT RETIREMENT CENTER, IN C., d/b/a NORTH PORT | RETIREMENT CENTER, hereinafter referred to as “Respondent, ” pursuant to Sections 120.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $500.00 against the Respondent, pursuant to Sections 400.414, 400.419(1)(c ), and 400.428, Florida Statutes; Rule 58A-5.023(1)(b), Florida Administrative Code. 2. The Respon dent «2s cited for a deficiency during a Biennial survey condu cted on or about January 8, 2004. The deficiency cited was a repeat Class Ill deficiency from the survey completed on February 20, 200: 2, and corrected on April 24, 2002. JURISDICTION AND VENUE 3. This tribunal has jurisdiction over the Respondent pursuant to Sections 120.569 and 120.57, Florida Statutes. 4. Venue shall be determined pursuant to Chapter 28-106.207, Florida Administrative Code. PARTIES 5. Pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules. 6. The Respondent is an assisted living facility located at 4950 Pocatella Avenue, North Port, Florida 34287. The Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part IU, Florida Statutes, and Chapter 58A- 5, Florida Administrative Code, having been issued license number 7860. COUNT I The Respondent operated beyond the scope of their standard license by performing Extended Congregate Care. § 400.414, Fla. Stat. § 400.419(1)(c), Fla. Stat. § 400.428, Fla. Stat. § 400.407(3), Fla. Stat. § 400.447(1), Fla. Stat. Fla. Admin. Code R. 58A-5.033(5)(a)2 7. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 8. On or about February 20, 2002, AHCA conducted Biennial survey at the Respondent's facility. AHCA cited the Respondent for a deficiency, based on the findings below, to wit: a) b) ¢) d) Observation during a tour of the facility on 2/18/02 at approximately 9:45 a.m. revealed Resident #3 and #4 were wearing TED hose. Review of Resident #3’s medical record revealed a physician order dated 11/2/01 with a diagnosis of deep vein thrombosis and an order for TED hose. Review of Resident #4’s medical record revealed a physician order dated 2/5/02 with a diagnosis of dependent edema and an order for TED hose bilateral on in AM off in PM. Interview with staff revealed staff were applying and removing the TED hose for the residents. Further interview with the Administrator and Nurse Manager revealed they were not aware these were Extended Congregate Care services. 9. The Respondent operated beyond the scope of their standard license, as required by § 400.407(3), Fla. Stat., § 400.447(1), Fla. Stat. and Fla. Admin. Code R. 58A-5.033(5)(a)2. 10. For this deficiency, AHCA provided the Respondent a mandated correction date of March 20, 2002. 11. The foregoing deficiency constitutes a Class III deficiency, to wit: “(c) Class III violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class II] violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation...” (§ 400.419(1)(c), Fla. Stat.) 12. On or about April 24, 2002, AHCA conducted a re-visit survey at the Respondent’s facility and found the deficiency corrected. 13. On or about January 8, 2004, AHCA conducted a Biennial survey at the Respondent’s facility. AHCA cited the Respondent for a repeat violation, based on the findings below, to wit: a) b) ¢) On 1/7/04 at approximately 11:45 a.m., a staff member was observed removing an oxygen container from Random Sampled Resident #9 in the dining room. The O, tubing was still on the resident and inserted into the nasal passages. The staff member returned at approximately 11:49 a.m. and re-connected the O, unit onto the resident. On 1/8/04, an interview was conducted with a facility management staff person at approximately 11:00 a.m. She stated she was not aware the facility could not provide the O, service to the residents under the facility standard license. She had identified in previous conversation that staff filled O, containers for the residents. She provided the survey team with a list of eight residents who had Op. Seven of the eight were identified as needing assisted living services per this staff person. d) A tour of the central oxygen refilling area was conducted on 1/8/04 at approximately 11:30 a.m. The hall door leading to this area had a sign on it stating this was an employee area only. 13. The foregoing deficiency constitutes a repeat Class Il deficiency, and warrants a fine of $500.00, to wit: “(c) Class III violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class Jor class II violations. A class III violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation...” (§ 400.419(1)(c), Fla. Stat.) WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count. 2. Impose a fine in the amount of $500.00, for the referenced violation. yin . Submitted on this , if ‘ey or AANA RN , 2004. Senior Attorney NOTICE The Respondent, NORTH PORT RETIREMENT CENTER, INC., d/b/a NORTH PORT RETIREMENT CENTER, is notified that it has a nght to request an adminisivative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Office of the General Counsel, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida 32308; Attention: Lealand McCharen, Agency Clerk. 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 RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Return Receipt Requested to North Port Retirement Center, Inc., d/b/a North Port Retirement Center, 4950 Pocatella Avenue, NS ai Port, Florida 34287. Submitted on this 2 (04 day of\\ | awa aN , 2004. _Aoanna Daniels, Senior Attorney Fla. Bar. No. 0118321 Counsel for Petitioner Agency for Health Care Administration 2727 Mahan Drive Building 3, Mail Stop #3 Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 921-0158 (fax) in

Docket for Case No: 04-001186