STATE OF FLORIDA ACERSY CLER AGENCY FOR HEALTH CARE ADMINISTRATION Mu WIT PF 13 AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2004003690 Return Receipt Requested: 7002 2410 0001 4237 0836 Petitioner, Vv. LOVE VILLAGE, INC., d/b/a LOVE VILLAGE, a U-\q | Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration * (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Love Village, Inc., d/b/a Love Village (hereinafter “Love Village”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $2,000 pursuant to Section 400.419, Florida Statutes (2003), for the protection of the public health, safety and welfare and $385.50 survey fee pursuant to Section 400.419(10), and 400.428(3)(c), Fla. Stat. (2003) JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Miami-Dade County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2003), and Chapter 58A-5, Florida Administrative Code. 5. Love Village operates a 6-bed assisted living facility located at 11060 S.W. 58h Terrace, Miami, Florida 33173. Love Village is licensed as an assisted living facility license number AL7548, with an expiration date of December 04, 2004. Love Village was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I LOVE VILLAGE FAILED TO PROVIDE APPROPRIATE CARE AND SERVICES TO THE NEEDS OF THE RESIDENTS 58A-5.0182, Florida Administrative Code (RESIDENT CARE STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on 03/25/2004 and based on record review and interview it was determined that the facility did not ensure that, all residents receive their medications as ordered by the physician. 8. Facility tour conducted on 3/25/04 at 11:30 A.M. revealed that, sampled resident #2 had a doctor’s order for Zocor 20 mg to be given at 8:00 p.m. The prescription for Zocor 20mg was filled on 3/11/2004 with 30 tablets but there were 29 tablets in the bottle at the time of the survey on 3/25/2004. 9. Interview with the administrator on 3/25/2004 at 12:00 p.m. revealed and confirmed that there were 29 tablets of Zocor 20 mg in the bottle. 10. Record review revealed that the medication observation record (MOR) for sampled resident #2 was signed for the entire day at noon on 3/25/2004. Even though resident #2 had not received her/his 8:00 pm dosage of Zocor 20mg, the MOR was signed off as if the resident had already been given the medication. 11. Based on the foregoing, Love Village violated 58A- 5.0182, Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. COUNT II LOVE VILLAGE FAILED TO ENSURE THAT ALL RESIDENTS WERE FREE FROM ABUSE AND NEGLECT Section 400.428(1), Florida Statutes (RESIDENT CARE STANDARDS) CLASS II DEFICIENCY 12. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 13. During the complaint investigation conducted on 3/25/2004 and based on observation, interview, and record review the facility did not ensure that all residents were free from abuse and neglect. 14. Facility tour conducted on 3/25/04 at 11:30 a.m. revealed that sampled resident #2 reported physical and verbal abuse of being handled roughly by a staff member while receiving assistance with the shower, spraying hair spray in tne resident's eyes, being loud, rude, and yelling at the resident when requesting services. 15. Interview with the administrator on 3/25/04 at 12:00 p.m. revealed and confirmed that sampled resident #2 had reported physical and verbal abuse on 3/12/2004. 16. Record review revealed that sampled resident #2 had experienced physical and verbal abuse by a former staff member at the facility. 17. Based on the foregoing, Love Village violated Section 400.428(1), Florida Statutes, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $385.50 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and II. B. Assess an administrative fine of $2,000.00 against Love Village on Counts I and II for two Class II violations. Cc. Assess a survey fee of $385.50 against Love Village, pursuant to Sections 400.419(9), and 400.428(3) (c), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent 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 and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee, Florida 32308, attention Lealand McCharen, Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO R Mail Stop #3, Agency EC EIVE A REQUEST FOR 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. 1g he Lacacuny urdes A. Naranjo la. Bar 997315 Assistant General Counsel Agency for Health Care Administration 8350 N. W. Suite 103 Miami, Florida 33166 Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52°? Terrace Miami, Florida 33166 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 52™ Terrace CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Liria M. Saler, Administrator/ Registered Agent, Love Village, 11060 S.w. 58'® Terrace, Miami, Florida 33173 on [1g a4 2004. fact, Lemans, Ardes A. Naranjo

Docket for Case No: 04-002979