STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 64- 20104 Petitioner, AHCA NO: 2004002840 vs. 2004002893 2004003217 THE APPLE HOUSE, INC. Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA or the Agency), by and through its undersigned counsel, and files this Administrative Complaint against The Apple House, Inc. (also known as “Apple House, Inc. (The),” and hereinafter “Respondent”, “Facility,” or “APPLE HOUSE”), pursuant to section 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTION 1. This is an action: (a) to impose an administrative fines upon Respondent, APPLE HOUSE, in the amount of Nine Thousand and No/100 Dollars ($9,000.00) pursuant to sections 400.419(2)(a) and (c), Florida Statutes (2003), based on one (1) class I deficiency as described below in COUNT I, and four (4) class II deficiencies as described below in COUNTS II, III, IV and V, respectively; and (b) to revoke the Facility’s license pursuant sections 400.414(1)(e)1., and 2., Florida Statutes (2003), as described below in COUNT VI. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to sections 120.569 and 120.57, Florida Statutes (2003). 3. AHCA has jurisdiction pursuant to Chapter 400, Part III, Florida Statutes, (2003). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2003). PARTIES 5. AHCA is the regulatory agency responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes, and rules governing assisted living facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part III, Florida Statutes; and Chapter 58A-5, Florida Administrative Code (2003), respectively. 6. Respondent, The Apple House, Inc., owns and operates an assisted living facility in the State of Florida. The facility, APPLE HOUSE (“Facility”), is a twenty-six bed assisted living facility located at 422 Pleasant Street, Pomona Park, Putnam County, Florida 32181. Respondent is licensed as an assisted living facility, having been issued license #8345. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes, and rules. COUNT I CLASS I VIOLATION FOR FAILURE TO MAINTAIN A SYSTEM TO PROVIDE TIMELY REFILL OF MEDICATIONS TO PREVENT MISSED DOSES 400.4255(1), and 400.4256 Florida Statutes Rule 58A-5.0185, Florida Administrative Code 7. AHCA re-alleges and incorporates herein by reference paragraphs 1 through 6 as if fully set forth herein. 8. The relevant statutory and regulatory provisions respectively read as follows: a. §400.4255(1), Florida Statutes (2003), Use of personnel; emergency care.-- (a) Persons under contract to the facility, facility staff, or volunteers, who are licensed according to part I of chapter 464, or those persons exempt under s. 464.022(1), and others as defined by rule, may administer medications to residents, take residents’ vital signs, manage individual weekly pill organizers for residents who self- administer medication, give prepackaged enemas ordered by a physician, observe residents, document observations on the appropriate resident's record, report observations to the resident's physician, and contract or allow residents or a resident's representative, designee, surrogate, guardian, or attorney in fact to contract with a third party, provided residents meet the criteria for appropriate placement as defined in s. 400.426. Nursing assistants certified pursuant to part II of chapter 464 may take residents’ vital signs as directed by a licensed nurse or physician. b. §400.4256, Florida Statutes (2003), Assistance with self-administration of medication.— (3) Assistance with self-administration of medication includes: (f) Keeping a record of when a resident receives assistance with self- administration under this section. (6) The department may by rule establish facility procedures and interpret terms as necessary to implement this section. rey) and c. Rule 58A-5.0185, Florida Administrative Code (2003), Medication Practices. Pursuant to Sections 400.4255 and 400.4256, F.S., and this rule, facilities holding a standard, limited mental health, extended congregate care, or limited nursing services license may assist with the self-administration or administration of medications to residents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule.... (7) MEDICATION LABELING AND ORDERS. (f) The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self- administration or medication administration are refilled in a timely manner. 9. AHCA conducted unannounced monitoring visits at Respondent’s facility on or about April 4, 2004. AHCA surveyors observed the following: a. Based on record review and staff interview the facility failed, for 7 out of 25 [#1,2,3,4, 6, 7 and 8] residents, to maintain a system to provide timely refills of medications which would prevent residents from missing doses of medication. Based on the conditions of the residents, the types of medications missed and the number of dosed missed, this failure to provide these medications in a timely manner has the potential to have a significant negative impact on the health of these residents. b. The findings include: 1, Review of the medication observation record (MOR) revealed that resident #1 had not received Ambien 10 milligrams (mg) (a sleeping medication) on 3/27/04 or on 3/28/04. During interview with the License Practical Nurse (LPN) on 3/29/04 at 10:40 AM, she stated that the resident had not taken the medication because he/she had run ovt and there were no refills in the medication cart. Interview with the Administrator at 10:45 AM revealed that she was unaware that this resident did not have his/her medication in the facility. The Adminis:rator looked through the resident's chart and was unable to locate written documentation to explain why the facility did not refill this medication prior to the resident running out of it. During the exit conference on 3/29/04 at 11:15 AM, the Administrator stated tnat she had contacted the pharmacy and that the medication would be delivered to the facility by 2:30 PM that day. Review of the MOR at approximately 4PM on 4/2/04 revealed that the resident #1 had not received one dose of Lasix (a diuretic to remove excess fluid from the body) 40mg. in the moming. Interview with the Assistant Director of Nurses (ADON) at that time revealed that the medication had been ordered from the pharmacy but had not been received yet. 2. While reviewing the MOR, with the LPN on 3/31/04 at approximately 11:25 AM, it was revealed that resident #2's Paxil 20 mg ( an anti-depressant) had a letter M on 3/6/04, 3/7/04, 3/8/04, and 3/9/04. When asked, the LPN stated that M stands for, "Medication Unavailable." She also stated that this medication is ordered by the facility, but she was not sure why they did not have this medication on those dates. She was unable to locate written documentation which would explain why the facility did not refill the medication prior to running out of it. 3. Further review of the MOR revealed that resident #3's Spironolactone (blood pressure medication) was unavailable from 3/10/04 thru 3/14/04. The LPN stated that the facility did not have the refill for this medication prior to resident running out of it. She also stated that this resident is a Hospice patient and that Hospice is providing the resident with a 15 day supply only. The LPN was unable to provide written documentation that they had requested the refills from the Hospice Nurse. 4. While reviewing the MOR with the LPN on 3/31/04, it was revealed that resident #6 did not receive the following 3 medications on the dates indicated: Paxil 10 mg and Exelon (Alzheimer's medication) 6 mg : March 1-17th and 23-30, 2004 (26 days out of 31 in March), and Norvasc ( blood pressure medication) 5 mg : March 7-17th and 23-30, 2004 (19 days out of 31). The LPN stated that the resident's family sends the resident's medication and that the family had not sent the medication before the resident ran out of it. The LPN further stated that the facility had notified the pharmacy and that the pharmacy had given them enough medication to cover the resident from 3/18/04-3/22/04, but when they ran out again, they still had not received the refills from the family. The LPN was unable to provide written documentation on their attempt to obtain the medications from the family. 5. Review of March, 2004 MOR for resident #7 revealed the resident did not receive Sodium Bicarb 600 mg, BID (twice a day), as ordered, from March 28-30, 2004. Interview with staff on 3/30/04 at epproximately 1:30 PM, revealed the resident had returned from the hospital and they had ordered the medication but they had not been delivered as of March 30, 2004. The staff also revealed that the other medications that the was receiving had been left over from before the resident went to the hospital. 6. During MOR review with the Day Supervisor on 3/31/04 at approximately 1:45 PM, it was revealed that resident #4's Depakote 250 mg medication was unavailable for the 5 PM and 8 PM dosages on 3/14/04 and the 8 AM, 5 PM, and 8 PM dosages from 3/15/04 thru 3/17/04. The Day Supervisor stated that the medication was not in the facility on those days. There was no written documentation on or behind the MOR explaining why the medication was not given. 7. During the exit interview with the Administrator on 3/31/04 at 2:20 PM , she stated that the new system had been implemented and that there is no reason for this problem to continue. 8. During an interview with the L.P.N.at 3:30 PM on 4/4/04, it was noted that resident #8 had missed the morning and noon doses of Reglan, a medication used to treat and prevent nausea. When asked, the nurse stated that the medication had been ordered on Friday, 4/2/04, but had apparently not come in. When asked about the procedure to be followed when medications did not come in, the nurse went into great detail about the "system" that was in place to order the medications; the procedure for calling the administrator to get emergency medications from the local pharmacy, and, in reference to the missed Reglan, how the nurse who was on duty the day before should have noticed that the medication was running low. Interview with the administrator at 4PM on 4/4/04 revealed that the pharmacy had been called and was sending a refill immediately. The administrator stated that all staff had been told to call her if medications were not refilled. 10. Respondent’s failure to follow regulations regarding medication practices for residents is a violation of section 400.4255(1)(a), Florida Statutes (2003), and Chapter 58A-5.0185(7)(f), Florida Administrative Code (2003). 11. On April 4, 2004, AHCA provided Respondent with a mandated correction date of April 5, 2004, within which to correct the violation. 12. Respondent’s failure to follow regulations managing medication practices for residents constitutes a class I violation. This class of violation is based upon the imminent danger that the Facility caused by failing to maintain a system so prescriptions for residents, who receive assistance with self-administration or medication administration, are refilled in a timely manner. The use of such a required system would prevent residents from missing doses of medication. The residents’ conditions for which the types of medicine and dosages were missed, exposed the residents to a substantial probability that death or physical or emotional harm would result. 13. Section 400.419(1)(a), Florida Statutes (2003), provides the definition of aclass I deficiency and the civil penalty for such deficiency, as follows: 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. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. A class I 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 14. In accordance with the above-stated facts and applicable law, AHCA determined that the subject violation warrants a fine of $5,000.00. COUNT I CLASS II VIOLATION FOR FAILURE TO DETERMINE THE APPROPRIATENESS OF ADMISSION TO THE FACILITY FOR EACH RESIDENT Rule 58A-5.018(1)(m)1., Florida Administrative Code 15. AHCA re-alleges and incorporates by reference paragraphs (1) through (6) above as if fully set forth herein. 16. The regulatory provision is pertinent to this alleged violation reads as follows: Rule 58A-5.0181, Florida Administrative Code (2003), Residency Criteria and. Admission Procedures (1) ADMISSION CRITERIA. An individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license.... (m) Have been determined to be appropriate for admission to the facility by the facility administrator. The administrator shall base his/her decision on: j. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 400.426, F.S., and subsection (2) of this rule; 2. The facility’s admission policy, and the services the facility is prepared to provide to arrange for to meet resident needs; and ... 17. AHCA surveyors conducted an Appraisal Visit at APPLE HOUSE on or about March 12, 2004, that resulted in a class II deficiency cited against APPLE HOUSE on findings below involving Resident #3. 18. The Facility failed to provide adequate care and services required by Rule 58A-5.0181(1)(m), Florida Administrative Code (2003), appropriate to the needs of residents accepted for admission to the facility as evidenced for Resident #3 by the following: a. Based on observation, record review, and interview, the administrator failed to determine that 1 (#3) of 19 sampled residents was inappropriate to the facility due to the level of care necessary to maintain the resident’s health. b. The findings include: 1. On or about March 12, 2004, approximately 10:45 AM, during tour of the facility, resident #3 was observed.in a hospital bed with an oxygen nasal cannula on, an a thoroughly saturated loose, blood tinged dressing on the left upper arm, a loose dressing on the left lower arm, dressings on the both lower extremities from the knees down, and an indwelling Foley catheter. The bed was noted to be in an elevated position to make it convenient for staff to provide care. Record review of the Health Assessment (1823) dated 12/13/03 revealed 2. That resident #3 had been admitted to the facility on [2/13/03 with the diagnosis of Acute Renal Failure, Congestive Heart Failure and liver Cancer. The resident was assessed as being non-weight bearing and a Hospice Resident. The physician did not document whether the resident’s needs could be met in an Assisted Living Facility. 3. Further review revealed the resident was not admitted to Hospice untill2/16/03, three days after admission to the ALF. 4. Continued review of the 1823 revealed that there was no soecial diet ordered or that any particular diet was indicated. However, review of the weight record revealed that the resident was on a renal diet. Further review of the weight record failed to reveal that a weight was taken on admission or at any other time. 19. On or about March 12, 2004, AHCA provided Respondent with a mandated correction date of April 12, 2004, within which to correct the referenced deficient practices. 20. Based on the foregoing, APPLE HOUSE violated the above-referenced provisions of Rule 58A-5.0181 Florida Administrative Code (2003), by the administrator failing to determine at the time of admission that a resident was inappropriate for residency in an assisted living facility. 21. The foregoing failure is a class II violation in that it directly threatened the physical or emotional health, safety, or security of Resident #3. Pursuant to Section 400.19, Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or emotional health, safety, or security of the facility residents, other than class I violations.” COUNT Ill CLASS I VIOLATION FOR UNAUTHORIZED PHYSICAL RESTRAINT USED ON 6 OF 19 RESIDENTS Rule 58A-5.0182(6)(h), Florida Administrative Code 22. AHCA re-alleges and incorporates by reference paragraphs (1) through (6) above as if fully set forth herein. 23. The regulatory provision that is pertinent to this alleged violation reads as follows: Rule 58A-5.0182, Florida Administrative Code (2003), Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility... (6) RESIDENT RIGHTS AND FACILITY PROCEDURES.... (h) Pursuant to Section 400.441, F.S., the use of physical restraints shall be limited to half-bed rails, and only upon the written order of the resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s representative. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance shall not be considered a physical restraint. 24. AHCA surveyors conducted a tour with a staff member of APPLE HOUSE on or about March 12, 2004, that resulted in a class II deficiency cited against APPLE HOUSE on findings below involving Residents #4,5,8,20,21 and 22. 25. The Facility failed to limit restraints to half-bed rails, and only upon the written order of the resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s representative, as evidence by the following: a. Based on observation and interview 6 of 19 residents were restricted in recliners to prevent them from rising up out of the recliners. b. The findings include: 1. Onor about March 12, 2004 at approximately 11 AM during tour with a staff member observation revealed 8 residents in chair-lift recliners in the common sitting area. Interview with the staff member revealed that 6 or the 8 residents were wheelchair bound. Further interview revealed the following information: a. Resident #4 was observed in a recliner with the chair reclined to the maximum and the electric control was lying on the floor out of the resident’s reach. The staff member indicated this resident’s reach. The staff member indicated this resident is non-ambulatory, hospice resident and requires assistance of two staff to transfer. This resident was not interviewable. b. Resident #5 was observed in a recliner with the chair reclined to the maximum and the electric control was lying on the floor out of the resident’s reach. Interview with the staff member revealed this resident can ambulate, but unsteady, on fall precautions and desires to lay on the floor so he/she is reclined to prevent him/her from getting on the floor. On 3/12/04 at approximately 7:30 PM the resident was observed sitting on the floor and the recliner he/she was in, was still in the reclined position. This resident is not interviewable. c. Resident #8 was observed in a recliner with the chair reclined to the maximum and the electric control was on the floor out of the resident’s reach. Interview with the staff member revealed the resident is non-ambulatory. On 3/12/04 at approximately 2 PM resident was observed in bed with the % bed rail positioned up and centered in the middle on the bed-frame. Interview with the staff member revealed the rails do slide up and down the edge of the bed. This resident was not interviewable. ; d. Resident #20 was observed in a recliner with the chair reclined to the maximum and the electric control was on the floor out of the resident’s reach. Interview with the staff person revealed the resident is ambulatory, blind, on fall precautions and receiving hospice services. e. Resident #21 was observed in a recliner with the chair reclined to the maximum and the electric control was on the floor out of the resident’s reach. Interview with the staff member revealed the resident is wheelchair bound. This resident was not interviewable. f. Resident #22 was observed in a recliner with the chair reclined to the maximum and the electric control was on the floor out of the resident’s reach. Interview with the staff member revealed the resident had ah istory of CVA (Cerebral Vascular Accident) but stands and pivots with transfer. Observation at that same time revealed a staff member lifted the resident out of the recliner and transferred him/her to the wheelchair. This resident was not interviewable. Review of the records revealed physician orders written on 2/24/04 for % bedrails for assistance. This was written as a verbal order per physician’s name/nurse name. 26. On or about March 12, 2004, AHCA provided Respondent with a mandated correction date of April 12, 2004, within which to correct the referenced deficient practices. 27. Based on the foregoing, APPLE HOUSE violated the above-referenced provisions of Rule 58A-5.0182(6)(h) Florida Administrative Code (2003), by the failure to limit restraints to half-bedrails, and only upon the written order of the resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s representative. 11 28. The foregoing unauthorized use of restraints is a class II violation in that it directly threatened the physical or emotional health, safety, or security of Residents #4,5,8,20,21 and 22. Pursuant to Section 400.19, Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or emotional health, safety, or security of the facility residents, other than class I violations.” COUNT IV CLASS II VIOLATION OF FOOD SERVICE STANDARD FOR A THERAPEUTIC DIET Rule 58A-5.0182(2)(e), Florida Administrative Code 29. AHCA re-alleges and incorporates by reference paragraphs (1) through (6) above as if fully set forth herein. 30. The regulatory provision that is pertinent to this alleged violation reads as follows: Rule 58A-5.0182, Florida Administrative Code (2003), Food Service Standards (2) DIETARY STANDARDS. (e) Therapeutic diets shall be prepared and served as ordered by the health care provider. j. Facilities that offer residents a variety of food choices through a select menu, buffet style dining or family style dining are not required to document what is eaten unless a health care provider’s order indicates that such monitoring is necessary. However, the food items which enable residents to comply with the therapeutic diet shall be identified on the menus developed for use in the facility. 31. AHCA surveyors on or about March 12, 2004, observed, reviewed records and by interview revealed a class II deficiency cited against APPLE HOUSE on findings below involving Resident #5. 32. The Facility failed to ensure that liquids in the diet of Resident #5 were thickened as ordered by the Health Assessment. AHCA surveyors observed the following: - a. Based on observation, record review and interview revealed 1 (#5) of 5 residents had order for thickened liquids, a therapeutic diet, that was not followed. b. The findings include: 1. Review of resident #5 record on the Health Assessment (1823) revealed the resident was on a regular diet and that "all liquids needed to be thickened". Review of the Resident Medical History form revealed the resident chokes easily on liquids. a. On 3/12/04 at approximately 2:06 PM observation revealed resident # 5 sitting at the dining room table with a plate of uneaten food in front of him/her. The resident's eyes were closed and he/she did not open them when staff attempted to encourage him/her to eat. There was no drink in front of the resident and when questioned the staff immediately got a glass of ice water and put it in front of the resident. The resident at that time attempted to pick the glass up to drink. Staff were questioned as to what consistency the liquid was thickened and at that time the staff person took the glass from the resident's hand and stated "Oh yes that is suppose to be thickened”. The staff person put an unknown amount of powder form thickener in the glass, stirred it up and set it in front of the resident again. b. Observation revealed the powder had settled at the bottom of the glass and when the staff were questioned they took the glass again and added some more powder. Interview with the staff revealed they were not aware as to what consistency the liquids were to be thickened. c. Interview with the administrator revealed it was nectar consistency but agreed it was not written in the chart. She indicated that everyone just knew what the consistency was and thought it was posted in the kitchen. That was not observed and staff dict not indicate that it was posted in the kitchen. 33. On or about March 12, 2004, AHCA provided Respondent with a mandated correction date of April 12, 2004, within which to correct the referenced deficient practices. 34. Based on the foregoing, APPLE HOUSE violated the above-referenced provisions of Rule 58A-5.020, Florida Administrative Code (2003), by the failure to prepare and serve the therapeutic diet that all liquids needed to be thickened as ordered on the Health Assessment. 35. The foregoing failure is a class II violation in that it directly threatened the physical or emotional health, safety, or security of Resident #5. Pursuant to section 400.19, Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or emotional health, safety, or security of the facility residents, other than class I violations.” COUNT V CLASS II VIOLATION FOR FAILURE TO COMPLY WITH THE RESIDENT CARE STANDARDS ENUMERATED IN THE RESIDENT BILL OF RIGHTS Section 400.428(1), Florida Statutes 36. AHCA re-alleges and incorporates by reference paragraphs (1) through (6) above as if fully set forth herein. 37. The statutory guarantee applicable to this alleged violation reads as follows: §400.428, Florida Statutes (2003), Resident bill of rights— (1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal individuality, and need for privacy. 38. AHCA surveyors conducted a monitoring inspection visit at APPLE HOUSE on or about March 18, 2004, that resulted ipa class IT deficiency cited against APPLE HOUSE on findings below involving Resident #1. 39. The Facility failed to ensure that Resident#1! was free from neglect and treated with consideration and due recognition of a need for privacy pursuant to section 400.428, Florida Statutes (2003), as evidenced by the following: a. Based on observation and interview the facility failed to treat 1 of 6 residents (#1) in the common area with respect and dignity. b. The findings include: 1. On March 18, 2004 at approximately 10 AM observation revealed six residents in the common area, 5 of which were in recliners and resident #1 who was lying on the floor. The resident was on a blanket with his/her nightclothes pulled up to the waist and incontinent underwear exposed. The resident is a dementia resident and non-interview-able. At that time interviews with various staff members revealed, "He/she likes to lay on the floor, it is for safety reasons," but no one bothered to cover the resident up. When staff were questioned as to whether or not they would like to see their parent lying there like that, the reply was "No." and then they just walked away. There were residents of both male and female genders in the area. , 40. Onor about March 18, 2004, AHCA provided Respondent with a mandated correction date of April 18, 2004, within which to correct the referenced deficient practices. 41. Based on the foregoing, APPLE HOUSE violated the above-referenced provisions of section 400.28, Florida Statutes (2003), by not covering the exposed patient and treating him with consideration and recognizing his need for privacy. 42. The foregoing failure is a class II violation in that it directly threatened the physical or emotional health, safety, or security of Resident #1. Pursuant to Section 400.19, Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or emotional health, safety, or security of the facility residents, other than class I violations.” COUNT VI STATUTORILY AUTHORIZED REVOCATION OF APPLE HOUSE’S LICENSE AS A RESULT OF THE FACILITY HAVING BEEN CITED WITH ONE (1) CLASS I DEFICIENCY AND FOUR (4) CLASS II DEFICIENCIES Section 400.414, Florida Statutes 43. AHCA re-alleges and incorporates by reference paragraphs (1) through (42) above as if fully set forth herein. 44, Citing section 400.419 for the definition of violation classifications, section 400.414, Florida Statutes (2003), is the authority for AHCA to revoke the license of any assisted living facility that is cited for one of the following deficiencies or groups of deficiencies: 1. One or more cited class I deficiencies. 2. Three or more cited class II deficiencies. 3. Five or more cited class III deficiencies that have been cited on a single survey and have not been corrected within the times specified. 45. APPLE HOUSE was cited in a survey on or about April 4, 2004, with one (1) Class I deficiency. 46. APPLE HOUSE was cited in survey on or about March 12, 2004, with three (3) class I deficiencies and in another survey on or about. March 18, 2004, with one (1) additional class II deficiency for a total of four (4) class II deficiencies. 47. Based on the foregoing, APPLE HOUSE violated the above-referenced provisions of section 400.414, Florida Statutes (2003), having been cited for both one (1) class I deficiency and four (4) class II deficiencies. This class I violation, in, of and by itself, warrants the revocation of the Facility’s license by AHCA as authorized by Section 400.414(e)1., Florida Statutes (2003). Even prior to the fourth class II violation on March 18, 2004, the three earlier class II violations were legally sufficient to revoke the Facility’s license pursuant to Section 400.41 4(e)2., Florida Statutes (2003). The one (1) class | violation; and/or group of four (4) class II violations, separately or cumulatively, warrant the revocation of the Facility’s license by AHCA. DISPLAY OF NOTIFICATION OF REVOCATION Pursuant to Section 400.414(7), Florida Statutes (2003), APPLE HOUSE shall post the notification of license revocation at the facility in a location visible to the public. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1, Factual and legal findings in favor of the Agency on Court I, II, ill, TV, V, and VI; . 2. _Iraposition of the administrative fines in the total amount of $9,000.00 for Counts I, II, IL, IV. and V (consisting of $5,000.00 on Count I and an additional $1,000.00 each for the Counts II, 11, IV, and Vv). 3. Revocation of the Facility’s license. NOTICE : IMGe aa Apple House hereby is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). 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 a hearing shall be sent to Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida, 32308. THE APPLE HOUSE, INC., IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT BY THE APPLE HOUSE, INC., A FINAL ORDER WILL BE RENDERED BY THE AGENCY FINDING THE DEFICIENCY AND/OR VIOLATION CHARGED AND IMPOSING THE PENALTY SOUGHT IN THE ADMINISTRATIVE COMPLAINT. Respectfully submitted on this S day of May 2004. ERIC R. BREDEMEYER FL Bar No.: 318442 Respondent’s Counsel Assistant General Counsel Agency For Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 (850) 921-0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that one original Administrative Complaint has been sent via certified mail return receipt requested (return receipt # 700) O360 0003 3904 3913 ) to Administrator, The Apple House, Inc., 422 Pleasant St., Pomona Park, Fl 32181 and that one original Administrative Complaint has been sent via certified mail return receipt requested (return receipt #_700\1 0360 0003 3804 3790 ) to Linda M. Holsapple, Registered Agent, P. O. Box 49, Pomona Park, FL 32181, on this cs) day of May 2004. COMPLETE TH:S SECT;ON ON DELIVERY R: COMPLETE THIS SECTION Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: THE APPLE HOUSE, jNC. ATTENTION: ADMINISTRATOR 22 PLEASANT ST. POMONA FARK, FL 3Z1¢] OO Registered i Return Receipt for Merchandis: 0 Insured Mait Oc.o.0. 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number (Transfer from service abo, «= CUO O3b0 0003 3604 3613 — eee PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-15- SENDER: COMPLETE THIS SECTION @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse so that we can return the card to you. Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: LINDA HOLSAP pb HOLS APPLE, FOR, THE APPLE HOUSE INC, Po, BOX Ug POMONA PARK, FL 3218} 3. Service Type 77” oo Oe BA Certified Mai press Kim D Registered * smn Reciot for Merchandis: C Insured Mail (AC. “. 4. Restricted Delivery? pom Fee) ot Yes 2. Article Number (Transfer from service label) 7001 0360 o003 3404 3790 PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-15 U.S. Postal Service : CERTIFIED MAIL RECEIPT. (Domestic Mail Only; No insurance Coverage Provided) +U.S, Postal Service “CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) ADM ICATIVE AM”AIWSTEANVE Here MAYES, 2004 EDL sate $ T Postage |S | COMPLAMY Postage | $ | COMALA CT THE Apree —— - > fied Mee | ee © conivioe tee THE Artls House | { i an . Posimars eipt Fee | Postmark Total Postege & Fees Senitc _ ADMIN STEATOR 0360 0003 3804 3813 7001 0360 0003 3404 3796 =) Permit No. 6-10. ; First-Class Mail ERr er Feslage & Fees Paid Unitep States Posta Servi8®™-< aC * Sender: Please print ret napeacres. and ZIP+4 in this box* “| . AGENCY FoR LEALTH CARE ADMINISTRATION ATTENTION: ERIC R, BREDEMEYER, SEMICE ATIORMEY 2727 MAHAN PRivE, BLOG #3, MSC#S TALLAHASSEE, FiokiDA 32308 ee EGER Cb Neolles tila Patarstiba tebe los strabe tee Dgtict As [lk * Sender: Please print Quename address, and ZIP+4 in this box * AGENCY FoR BEALTH CARE ADMINISTRATI OFFICE oF THE GENERAL CounSEL ATTN: ERIC R, BREDEMEYER, CR ATTY, 2727 MAYAN DR., BLDG#3, MSC #3 TALLAHASSEE EL 22309 First-Class Mail Postage &-Fees-Paid: USPS SI Permit No. G-10 Unrrep States PosTAL SERVICRT Es CN | EOE EAE CY fartbersdetealbsttarbachiadebrsli tM vadeaded Mardy bial

Docket for Case No: 04-002069